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Sue-Chue-Lam C, Brezden-Masley C, Sutradhar R, Yu AYX, Baxter NN. Trends and Prescriber Variation in the Duration of Oxaliplatin-Containing Adjuvant Chemotherapy for Stage III Colon Cancer From 2007 to 2019: A Population-Based Retrospective Cohort Study. Clin Colorectal Cancer 2023; 22:431-441.e9. [PMID: 37648568 DOI: 10.1016/j.clcc.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/04/2023] [Accepted: 08/05/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION The International Duration Evaluation of Adjuvant Therapy (IDEA) collaboration in 2017 established 3 months of adjuvant therapy as an alternative to 6 months of therapy for stage III colon cancer. We determined the association between the IDEA publication, changes in clinical practice, and prescriber variation. PATIENTS AND METHODS Using linked databases, we identified Ontarians aged ≥18 years at diagnosis of stage III colon cancer between 2007 and 2019 who received oxaliplatin-containing adjuvant therapy. The outcome was duration of therapy, categorized as ≤25%, >25% to ≤50%, >50% to ≤75%, and >75% of a 6-month course of therapy to approximate treatment durations in the IDEA collaboration. We examined trends in duration over time using an interrupted time series regression model. We analyzed treatment duration after accounting for patient and prescriber characteristics, using multivariable mixed effects logistic regression models to quantify between-prescriber variation. RESULTS We included 4695 patients with stage III colon cancer who received oxaliplatin-containing adjuvant chemotherapy, of whom 77.5% initiated treatment pre-IDEA and 22.5% initiated treatment post-IDEA. Post-IDEA, there was a 16.4% (95% CI, 12.5%-20.3%) absolute increase in the proportion of patients treated with ≤50% of a maximal course of therapy. This trend was greatest among patients with low-risk tumors. Prescriber variation increased pre-IDEA to 15.6% post-IDEA (variance partition coefficient 5.4% pre-IDEA and 15.6% post-IDEA). CONCLUSION The publication of IDEA was associated with increases in short duration adjuvant therapy and prescriber-level practice variation for stage III colon cancer. Clinicians should be better supported to make consistent recommendations about adjuvant duration under conditions of uncertainty and trade-offs.
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Affiliation(s)
- Colin Sue-Chue-Lam
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Christine Brezden-Masley
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Medical Oncology, Sinai Health System, Mount Sinai Hospital, Toronto, Canada
| | - Rinku Sutradhar
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Amy Y X Yu
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nancy N Baxter
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Melbourne School of Global and Population Health, University of Melbourne, Melbourne, Australia.
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See C, Wheelock KM, Caraballo C, Khera R, Annapureddy A, Mahajan S, Lu Y, Krumholz HM, Murugiah K. Patterns of Digoxin Prescribing for Medicare Beneficiaries in the United States 2013-2019. Am J Med Open 2023; 10:100048. [PMID: 38213879 PMCID: PMC10783702 DOI: 10.1016/j.ajmo.2023.100048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Background Studies show that digoxin use is declining but is still prevalent. Recent data on digoxin prescription and characteristics of digoxin prescribers are unknown, which can help understand its contemporary use. Methods Using Medicare Part D data from 2013 to 2019, we studied the change in number and proportion of digoxin prescriptions and digoxin prescribers, overall and by specialty. Using logistic regression, we identified prescriber characteristics associated with digoxin prescription. Results From 2013 to 2019, total digoxin prescriptions (4.6 to 1.8 million) and proportion of digoxin prescribers decreased (9.1% to 4.3% overall; 26.6% to 11.8% among General Medicine prescribers and 65.4% to 48.9% among Cardiology). Of digoxin prescribers from 2013 practicing in 2019 (91.2% remained active), 59.1% did not prescribe digoxin at all, 31.7% reduced, and 9.2% maintained or increased prescriptions. The proportion of all digoxin prescriptions that were prescribed by General Medicine prescribers declined from 59.7% to 48.2% and increased for Cardiology (29% to 38.5%). Among new prescribers in 2019 (N = 85,508), only 1.9% prescribed digoxin. Digoxin prescribers when compared to non-digoxin prescribers were more likely male, graduated from medical school earlier, were located in the Midwest or South, and belonged to Cardiology (all P < .001). Conclusions Digoxin prescriptions continue to decline with over half of 2013 prescribers no longer prescribing digoxin in 2019. This may be a result of the increasing availability of newer heart failure therapies. The decline in digoxin prescription was greater among general medicine physicians than cardiologists, suggesting a change in digoxin use to a medication prescribed increasingly by specialists.
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Affiliation(s)
- Claudia See
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Kevin M. Wheelock
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - César Caraballo
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
| | - Amarnath Annapureddy
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Shiwani Mahajan
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
| | - Yuan Lu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Conn
| | - Karthik Murugiah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
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Lyhmann I, Widding-Havneraas T, Zachrisson HD, Bjelland I, Chaulagain A, Mykletun A, Halmøy A. Variation in attitudes toward diagnosis and medication of ADHD: a survey among clinicians in the Norwegian child and adolescent mental health services. Eur Child Adolesc Psychiatry 2023; 32:2557-2567. [PMID: 36401019 PMCID: PMC10682209 DOI: 10.1007/s00787-022-02110-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/05/2022] [Indexed: 11/20/2022]
Abstract
Prevalence and medication rates of ADHD vary geographically, both between and within countries. No absolute cutoff exists between ADHD and normal behavior, making clinician attitudes (leading to local practice cultures) a potential explanation for the observed variation in diagnosis and medication rates. The objective of this study was to describe variation in attitudes toward diagnosis and medication of ADHD among clinicians working in child and adolescent mental health services (CAMHS). We hypothesized that attitudes would vary along a spectrum from "restrictive" to "liberal". We also explored whether differences in attitudes between clinicians were related to professional background and workplace (clinic). A survey in the form of a web-based questionnaire was developed. All CAMHS outpatient clinics in Norway were invited. Potential respondents were all clinicians involved in diagnosing and treating children and adolescents with ADHD. To investigate the existence of attitudes toward diagnosis and medication as latent constructs, we applied confirmatory factor analysis (CFA). We further examined how much of variance in attitudes could be ascribed to profession and clinics by estimating intraclass correlation coefficients. In total, 674 respondents representing 77 (88%) of the clinics participated. We confirmed variation in attitudes with average responses leaning toward the "restrictive" end of the spectrum. CFA supported "attitude toward diagnosis" and "attitude toward medication" as separate, and moderately correlated (r = 0.4) latent variables, representing a scale from restrictive to liberal. Professional background and workplace explained only a small part of variance in these attitudes.
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Affiliation(s)
- Ingvild Lyhmann
- Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Tarjei Widding-Havneraas
- Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Ingvar Bjelland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Ashmita Chaulagain
- Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Arnstein Mykletun
- Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
- UiT - The Arctic University of Norway, Tromsø, Norway
- Nordland Hospital Trust, Centre for Work and Mental Health, Bodø, Norway
- Division of Mental Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Anne Halmøy
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
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Forss M, Bolsunovskyi K, Lee Y, Kilpeläinen TP, Aoki Y, Gudjonsson S, Hervé F, Järvinen P, Malde S, Miyazawa K, Sairanen J, Sander L, Violette PD, Witte LP, Guyatt GH, Tikkinen KA. Practice Variation in the Management of Adult Hydroceles: A Multinational Survey. EUR UROL SUPPL 2023; 58:1-7. [PMID: 38152484 PMCID: PMC10751538 DOI: 10.1016/j.euros.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 12/29/2023] Open
Abstract
Background Although hydrocele is one of the most common urologic pathologies, it is seldom studied, and the major urologic associations have no guidelines for the management of adult hydroceles. Objective To characterize international practice variation in the treatment of adult hydroceles. Design setting and participants An international survey was conducted addressing the management of hydroceles among urologists in Belgium, Denmark, Finland, Iceland, Japan, and the Netherlands from September to December 2020. We invited a random sample of 170 urologists from each country (except Iceland). Outcome measurements and statistical analysis Urologists' treatment options, factors relevant for decision-making, expected patient satisfaction, and outcomes after aspiration versus surgery were assessed. Results and limitations Of the 864 urologists contacted, 437 (51%) participated. Of the respondents, 202 (53%) performed both hydrocelectomies and aspiration, 147 (39%) performed hydrocelectomies only, and 30 (8%) performed aspiration only. In Belgium (83%), the Netherlands (75%), and Denmark (55%), urologists primarily performed hydrocelectomies only, whereas in Finland (84%), Japan (61%), and Iceland (91%), urologists performed both hydrocelectomies and aspiration. Urologists favored hydrocelectomy for large hydroceles (78.8% vs 37.5% for small), younger patients (66.0% for patients <50 yr vs 41.2% for ≥70 yr), patients with few or no comorbidities (62.3% vs 23.1% with multiple comorbidities), and patients without antithrombotic agents (53.5% vs 36.5% with antithrombotic agents). Most urologists considered patient satisfaction to be highest after hydrocelectomy (53.8% vs 9.9% after aspiration) despite believing that hydrocelectomy is more likely to cause complications (hematoma 77.8% vs 8.8% after aspiration). Estimates varied between countries. Conclusions We found a large variation in the treatment of adult hydroceles within and between countries. Optimization of hydrocele management globally will require future studies. Patient summary Our international survey shows that treatment of adult hydrocele varies considerably within and between countries.
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Affiliation(s)
- Mikko Forss
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Kostiantyn Bolsunovskyi
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Tuomas P. Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Yoshitaka Aoki
- Department of Urology, University of Fukui Faculty of Medical Sciences, Fukui, Japan
| | - Sigurdur Gudjonsson
- Department of Urology, Landspitali University Hospital; Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - François Hervé
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Petrus Järvinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sachin Malde
- Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | | | - Jukka Sairanen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lotte Sander
- Department of Urology, Aalborg University Hospital, Aalborg, Denmark
| | - Philippe D. Violette
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Division of Urology, Department of Surgery, McMaster University, Hamilton, ON, Canada
- Department of Surgery, Woodstock Hospital, Woodstock, ON, Canada
| | | | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kari A.O. Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
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Tanaka K, Hayashi R, Ariyama Y, Takahashi N, Namba F. Management of bronchopulmonary dysplasia in Japan: A nationwide survey. Early Hum Dev 2023; 186:105867. [PMID: 37788509 DOI: 10.1016/j.earlhumdev.2023.105867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/21/2023] [Accepted: 09/23/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND The incidence of bronchopulmonary dysplasia (BPD) and respiratory management practices for extremely low birth weight infants (ELBWIs) widely vary among institutions and countries. AIMS To clarify the variation and characteristics of the current practices of Japanese neonatologists managing patients with BPD. STUDY DESIGN Questionnaire-based survey. PARTICIPANTS Level II and III perinatal centers certified by the Japan Society of Perinatal and Neonatal Medicine. OUTCOME MEASURES Policies of the neonatal intensive care units (NICUs) regarding respiratory care and medications for BPD prevention and treatment. RESULTS A total of 76 % of facilities (207/274) responded to our survey. The response rates of level III and II facilities were 91 % (102/112) and 35 % (105/296), respectively. INtubation-SURfactant-Extubation and Less Invasive Surfactant Administration methods were performed in 23 % (47/206) and 1 % (3/206) of facilities, respectively. For the prophylactic purpose, systemic and inhaled steroids were administered "frequently" or "occasionally" in 14 % (28/205) and 42 % (86/204) of NICUs, respectively. For the therapeutic purpose, systemic and inhaled steroids were administered "frequently" or "occasionally" in 84 % (171/204) and 29 % (59/204) of NICUs, respectively. Approximately half of the NICUs (99/202) used volume-targeted ventilation (VTV) "frequently" or "occasionally" in progressing BPD. High-frequency oscillation ventilation (HFOV) was used for progressing BPD "frequently" and "occasionally" in 89 % (180/202) of the facilities. CONCLUSIONS Our study provided an overview and characteristics of BPD management in Japan in recent years. Noninvasive approaches with surfactant administration remain not widely used in Japan. HFOV is a widely accepted management for progressing BPD.
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Affiliation(s)
- Kosuke Tanaka
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan.
| | - Ryo Hayashi
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Yuta Ariyama
- Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Naoto Takahashi
- Department of Pediatrics, The University of Tokyo Hospital, Bunkyo, Tokyo, Japan
| | - Fumihiko Namba
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
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van Essen TA, van Erp IA, Lingsma HF, Pisică D, Yue JK, Singh RD, van Dijck JT, Volovici V, Younsi A, Kolias A, Peppel LD, Heijenbrok-Kal M, Ribbers GM, Menon DK, Hutchinson PJ, Manley GT, Depreitere B, Steyerberg EW, Maas AI, de Ruiter GC, Peul WC. Comparative effectiveness of decompressive craniectomy versus craniotomy for traumatic acute subdural hematoma (CENTER-TBI): an observational cohort study. EClinicalMedicine 2023; 63:102161. [PMID: 37600483 PMCID: PMC10432786 DOI: 10.1016/j.eclinm.2023.102161] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/22/2023] Open
Abstract
Background Limited evidence existed on the comparative effectiveness of decompressive craniectomy (DC) versus craniotomy for evacuation of traumatic acute subdural hematoma (ASDH) until the recently published randomised clinical trial RESCUE-ASDH. In this study, that ran concurrently, we aimed to determine current practice patterns and compare outcomes of primary DC versus craniotomy. Methods We conducted an analysis of centre treatment preference within the prospective, multicentre, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (known as CENTER-TBI) and NeuroTraumatology Quality Registry (known as Net-QuRe) studies, which enrolled patients throughout Europe and Israel (2014-2020). We included patients with an ASDH who underwent acute neurosurgical evacuation. Patients with severe pre-existing neurological disorders were excluded. In an instrumental variable analysis, we compared outcomes between centres according to treatment preference, measured by the case-mix adjusted proportion DC per centre. The primary outcome was functional outcome rated by the 6-months Glasgow Outcome Scale Extended, estimated with ordinal regression as a common odds ratio (OR), adjusted for prespecified confounders. Variation in centre preference was quantified with the median odds ratio (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582). Findings Between December 19, 2014 and December 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI of whom 336 (7%) underwent acute surgery for ASDH evacuation; 91 (27%) underwent DC and 245 (63%) craniotomy. The proportion primary DC within total acute surgery cases ranged from 6 to 67% with an interquartile range (IQR) of 12-26% among 46 centres; the odds of receiving a DC for prognostically similar patients in one centre versus another randomly selected centre were trebled (adjusted median odds ratio 2.7, p < 0.0001). Higher centre preference for DC over craniotomy was not associated with better functional outcome (adjusted common odds ratio (OR) per 14% [IQR increase] more DC in a centre = 0.9 [95% CI 0.7-1.1], n = 200). Primary DC was associated with more follow-on surgeries and complications [secondary cranial surgery 27% vs. 18%; shunts 11 vs. 5%]; and similar odds of in-hospital mortality (adjusted OR per 14% IQR more primary DC 1.3 [95% CI (1.0-3.4), n = 200]). Interpretation We found substantial practice variation in the employment of DC over craniotomy for ASDH. This variation in treatment strategy did not result in different functional outcome. These findings suggest that primary DC should be restricted to salvageable patients in whom immediate replacement of the bone flap is not possible due to intraoperative brain swelling. Funding Hersenstichting Nederland for the Dutch NeuroTraumatology Quality Registry and the European Union Seventh Framework Program.
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Affiliation(s)
- Thomas A. van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- Department of Surgery, Division of Neurosurgery, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Inge A.M. van Erp
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Hester F. Lingsma
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Dana Pisică
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - John K. Yue
- Brain and Spinal Injury Center, Department of Neurological Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Ranjit D. Singh
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Jeroen T.J.M. van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Victor Volovici
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Alexander Younsi
- Department of Neurosurgery, University Hospital Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Lianne D. Peppel
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Majanka Heijenbrok-Kal
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Gerard M. Ribbers
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - David K. Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J.A. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, Department of Neurological Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Bart Depreitere
- Department of Neurosurgery, University Hospital KU Leuven, Leuven, Belgium
| | - Ewout W. Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Andrew I.R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Godard C.W. de Ruiter
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Wilco C. Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
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de Graaff MR, Klaase JM, van Dam RM, Kuhlmann KFD, Kazemier G, Swijnenburg RJ, Elfrink AKE, Verhoef C, Mieog JS, van den Boezem PB, Gobardhan P, Rijken AM, Lips DJ, Leclercq WGK, Marsman HA, van Duijvendijk P, van der Hoeven JAB, Vermaas M, Dulk MD, Grünhagen DJ, Kok NFM. Survival of patients with colorectal liver metastases treated with and without preoperative chemotherapy: Nationwide propensity score-matched study. Eur J Surg Oncol 2023; 49:106932. [PMID: 37302900 DOI: 10.1016/j.ejso.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/10/2023] [Accepted: 05/06/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Routine treatment with preoperative systemic chemotherapy (CTx) in patients with colorectal liver metastases (CRLM) remains controversial due to lack of consistent evidence demonstrating associated survival benefits. This study aimed to determine the effect of preoperative CTx on overall survival (OS) compared to surgery alone and to assess hospital and oncological network variation in 5-year OS. METHODS This was a population-based study of all patients who underwent liver resection for CRLM between 2014 and 2017 in the Netherlands. After 1:1 propensity score matching (PSM), OS was compared between patients treated with and without preoperative CTx. Hospital and oncological network variation in 5-year OS corrected for case-mix factors was calculated using an observed/expected ratio. RESULTS Of 2820 patients included, 852 (30.2%) and 1968 (69.8%) patients were treated with preoperative CTx and surgery alone, respectively. After PSM, 537 patients remained in each group, median number of CRLM; 3 [IQR 2-4], median size of CRLM; 28 mm [IQR 18-44], synchronous CLRM (71.1%). Median follow-up was 80.8 months. Five-year OS rates after PSM for patients treated with and without preoperative chemotherapy were 40.2% versus 38.3% (log-rank P = 0.734). After stratification for low, medium, and high tumour burden based on the tumour burden score (TBS) OS was similar for preoperative chemotherapy vs. surgery alone (log-rank P = 0.486, P = 0.914, and P = 0.744, respectively). After correction for non-modifiable patient and tumour characteristics, no relevant hospital or oncological network variation in five-year OS was observed. CONCLUSION In patients eligible for surgical resection, preoperative chemotherapy does not provide an overall survival benefit compared to surgery alone.
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Affiliation(s)
- Michelle R de Graaff
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands; Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands.
| | - Joost M Klaase
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Koert F D Kuhlmann
- Department of Surgery, Antoni van Leeuwenhoek - Dutch Cancer Institute, Amsterdam, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Arthur K E Elfrink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Cees Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J Sven Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Paul Gobardhan
- Department of Surgery, Amphia Medical Centre, Breda, the Netherlands
| | - Arjen M Rijken
- Department of Surgery, Amphia Medical Centre, Breda, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | | | | | | | | | - Maarten Vermaas
- Department of Surgery, Ijsselland Hospital, Capelle aan de Ijssel, the Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Dirk J Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Niels F M Kok
- Department of Surgery, Antoni van Leeuwenhoek - Dutch Cancer Institute, Amsterdam, the Netherlands
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Ubels S, Matthée E, Verstegen M, Klarenbeek B, Bouwense S, van Berge Henegouwen MI, Daams F, Dekker JWT, van Det MJ, van Esser S, Griffiths EA, Haveman JW, Nieuwenhuijzen G, Siersema PD, Wijnhoven B, Hannink G, van Workum F, Rosman C, Heisterkamp J, Polat F, Schouten J, Singh P, Eshuis WJ, Kalff MC, Feenstra ML, van der Peet DL, Stam WT, Van Etten B, Poelmann F, Vuurberg N, Willem van den Berg J, Martijnse IS, Matthijsen RM, Luyer M, Curvers W, Nieuwenhuijzen T, Taselaar AE, Kouwenhoven EA, Lubbers M, Sosef M, Lecot F, Geraedts TC, van den Wildenberg F, Kelder W, Lubbers M, Baas PC, de Haas JW, Hartgrink HH, Bahadoer RR, van Sandick JW, Hartemink KJ, Veenhof X, Stockmann H, Gorgec B, Weeder P, Wiezer MJ, Genders CM, Belt E, Blomberg B, van Duijvendijk P, Claassen L, Reetz D, Steenvoorde P, Mastboom W, Klein Ganseij HJ, van Dalsen AD, Joldersma A, Zwakman M, Groenendijk RP, Montazeri M, Mercer S, Knight B, van Boxel G, McGregor RJ, Skipworth RJ, Frattini C, Bradley A, Nilsson M, Hayami M, Huang B, Bundred J, Evans R, Grimminger PP, van der Sluis PC, Eren U, Saunders J, Theophilidou E, Khanzada Z, Elliott JA, Ponten J, King S, Reynolds JV, Sgromo B, Akbari K, Shalaby S, Gutschow CA, Schmidt H, Vetter D, Moorthy K, Ibrahim MA, Christodoulidis G, Räsänen JV, Kauppi J, Söderström H, Koshy R, Manatakis DK, Korkolis DP, Balalis D, Rompu A, Alkhaffaf B, Alasmar M, Arebi M, Piessen G, Nuytens F, Degisors S, Ahmed A, Boddy A, Gandhi S, Fashina O, Van Daele E, Pattyn P, Robb WB, Arumugasamy M, Al Azzawi M, Whooley J, Colak E, Aybar E, Sari AC, Uyanik MS, Ciftci AB, Sayyed R, Ayub B, Murtaza G, Saeed A, Ramesh P, Charalabopoulos A, Liakakos T, Schizas D, Baili E, Kapelouzou A, Valmasoni M, Pierobon ES, Capovilla G, Merigliano S, Constantinoiu S, Birla R, Achim F, Rosianu CG, Hoara P, Castro RG, Salcedo AF, Negoi I, Negoita VM, Ciubotaru C, Stoica B, Hostiuc S, Colucci N, Mönig SP, Wassmer CH, Meyer J, Takeda FR, Aissar Sallum RA, Ribeiro U, Cecconello I, Toledo E, Trugeda MS, Fernández MJ, Gil C, Castanedo S, Isik A, Kurnaz E, Videira JF, Peyroteo M, Canotilho R, Weindelmayer J, Giacopuzzi S, De Pasqual CA, Bruna M, Mingol F, Vaque J, Pérez C, Phillips AW, Chmelo J, Brown J, Koshy R, Han LE, Gossage JA, Davies AR, Baker CR, Kelly M, Saad M, Bernardi D, Bonavina L, Asti E, Riva C, Scaramuzzo R, Elhadi M, Ahmed HA, Elhadi A, Elnagar FA, Msherghi AA, Wills V, Campbell C, Cerdeira MP, Whiting S, Merrett N, Das A, Apostolou C, Lorenzo A, Sousa F, Barbosa JA, Devezas V, Barbosa E, Fernandes C, Smith G, Li EY, Bhimani N, Chan P, Kotecha K, Hii MW, Ward SM, Johnson M, Read M, Chong L, Hollands MJ, Allaway M, Richardson A, Johnston E, Chen AZ, Kanhere H, Prasad S, McQuillan P, Surman T, Trochsler M, Schofield W, Ahmed SK, Reid JL, Harris MC, Gananadha S, Farrant J, Rodrigues N, Fergusson J, Hindmarsh A, Afzal Z, Safranek P, Sujendran V, Rooney S, Loureiro C, Fernández SL, Díez del Val I, Jaunoo S, Kennedy L, Hussain A, Theodorou D, Triantafyllou T, Theodoropoulos C, Palyvou T, Elhadi M, Ben Taher FA, Ekheel M, Msherghi AA. Practice variation in anastomotic leak after esophagectomy: Unravelling differences in failure to rescue. Eur J Surg Oncol 2023; 49:974-982. [PMID: 36732207 DOI: 10.1016/j.ejso.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/20/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Failure to rescue (FTR) is an important outcome measure after esophagectomy and reflects mortality after postoperative complications. Differences in FTR have been associated with hospital resection volume. However, insight into how centers manage complications and achieve their outcomes is lacking. Anastomotic leak (AL) is a main contributor to FTR. This study aimed to assess differences in FTR after AL between centers, and to identify factors that explain these differences. METHODS TENTACLE - Esophagus is a multicenter, retrospective cohort study, which included 1509 patients with AL after esophagectomy. Differences in FTR were assessed between low-volume (<20 resections), middle-volume (20-60 resections) and high-volume centers (≥60 resections). Mediation analysis was performed using logistic regression, including possible mediators for FTR: case-mix, hospital resources, leak severity and treatment. RESULTS FTR after AL was 11.7%. After adjustment for confounders, FTR was lower in high-volume vs. low-volume (OR 0.44, 95%CI 0.2-0.8), but not versus middle-volume centers (OR 0.67, 95%CI 0.5-1.0). After mediation analysis, differences in FTR were found to be explained by lower leak severity, lower secondary ICU readmission rate and higher availability of therapeutic modalities in high-volume centers. No statistically significant direct effect of hospital volume was found: high-volume vs. low-volume 0.86 (95%CI 0.4-1.7), high-volume vs. middle-volume OR 0.86 (95%CI 0.5-1.4). CONCLUSION Lower FTR in high-volume compared with low-volume centers was explained by lower leak severity, less secondary ICU readmissions and higher availability of therapeutic modalities. To reduce FTR after AL, future studies should investigate effective strategies to reduce leak severity and prevent secondary ICU readmission.
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Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Eric Matthée
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Moniek Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bastiaan Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Marc J van Det
- Department of Surgery, ZGT Hospital Group, Almelo, the Netherlands
| | - Stijn van Esser
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Jan Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | | | - Fatih Polat
- Canisius-Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Radboud University Medical Center, Nijmegen, the Netherlands
| | - Pritam Singh
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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Vink MDH, Portrait FRM, van Wezep TC, Koolman X, Mol BW, Bongers MY, van der Hijden EJE. Practice variation in the stepped care approach to idiopathic heavy menstrual bleeding: A population-based study. Eur J Obstet Gynecol Reprod Biol 2023; 283:6-12. [PMID: 36746074 DOI: 10.1016/j.ejogrb.2023.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/15/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Heavy menstrual bleeding (HMB) affects a quarter of all women, with half having no structural cause. Dutch guidelines recommend a stepped care approach to the management of such idiopathic HMB, starting with medication or a levonorgestrel-releasing intrauterine device (LNG-IUD), before progressing to endometrial ablation, and ultimately, hysterectomy. However, practice variation between hospitals could lead to suboptimal health outcomes and increased healthcare costs for some women. OBJECTIVES To evaluate adherence to stepped care for women with idiopathic HMB and to identify practice variation among Dutch hospitals. STUDY DESIGN This population-based cross-sectional study used Dutch insurance claims data from primary and secondary care for all women with idiopathic HMB referred to a gynecologist between January 2019 and December 2020. We calculated the average number of treatments in the 3 years before each treatment step at each hospital, making adjustments for age, socioeconomic status, and ethnicity. Variation in medical practice was measured by the coefficient of variation (CV). RESULTS We studied 20,715 women treated with LNG-IUDs (56%), endometrial ablation (36%), laparoscopic hysterectomy (13%), or vaginal hysterectomy (4%) in 93 hospitals. Before endometrial ablation, on average 47% used medication (hospital range 27%-71%; CV 0.17) and 16% used an LNG-IUD (hospital range 8%-29%, CV 0.32). Before hysterectomy, 52% (hospital range 28%-65%, CV 0.16) used medication, 21% (hospital range 6%-38%, CV 0.35) used an LNG-IUD, and 23% underwent endometrial ablation (hospital range 0%-59%, CV 0.55). On average, women underwent 0.63 (hospital range 0.36-1.00, adjusted rate 0.40-0.98, CV 0.17) and 0.96 (hospital range 0.56-1.45, adjusted rate 0.56-1.44, CV 0.18) treatments before endometrial ablation and hysterectomy, respectively. CONCLUSIONS Considerable practice variation exists among Dutch hospitals in the stepped care approach to idiopathic HMB. Improving adherence to this approach could improve quality of care and reduce costs.
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Affiliation(s)
- Maarten D H Vink
- Department of Health Economics, School of Business and Economics & Talma Institute, Vrije Universiteit, Amsterdam, the Netherlands; Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - France R M Portrait
- Department of Health Economics, School of Business and Economics & Talma Institute, Vrije Universiteit, Amsterdam, the Netherlands
| | | | - Xander Koolman
- Department of Health Economics, School of Business and Economics & Talma Institute, Vrije Universiteit, Amsterdam, the Netherlands
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Marlies Y Bongers
- Grow School of Oncology and developmental biology, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Obstetrics and Gynaecology, Maxima Medical Center, Veldhoven, the Netherlands
| | - Eric J E van der Hijden
- Department of Health Economics, School of Business and Economics & Talma Institute, Vrije Universiteit, Amsterdam, the Netherlands; Zilveren Kruis Health Insurance, Leiden, the Netherlands
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Abstract
Background: Practice variation may indicate a lack of evidence to guide management. This study investigated the preferences of operative management of proximal phalangeal fractures in Australian hand surgeons, as well as factors that may account for variations. Methods: An electronic survey of all members of the Australian Hand Surgery Society was performed. Surgeon demographic factors and surgical preferences were investigated. Three common proximal phalangeal fracture configurations were presented as cases. Potential predictors of management were explored. Results: A total of 51.9% of active hand surgeons responded. Orthopaedic surgeons were more comfortable with lateral plating and intramedullary screw fixation, while plastic surgeons preferred Kirschner wire (K-wire) fixation. Junior surgeons were more likely to believe that intramedullary screw fixation produced superior results. 53.0% of surgeons in a tertiary environment believed that adequate hand therapy was key (compared to 17.0% of clinicians in a secondary hospital). Conclusions: There is significant practice variation and a lack of standards in the management of a common clinical problem, as well as a lack of consensus on the evidence underpinning common fixation methods. Further research is needed. Level of Evidence: Level IV (Therapeutic).
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Affiliation(s)
- Brahman Sivakumar
- Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital, NSW, Australia
- Australian Research Collaboration on Hands (ARCH), Mudgeeraba, QLD, Australia
- The University of Sydney, Department of Surgery, Faculty of Medicine, Camperdown, NSW, Australia
| | - Mark Ross
- Brisbane Hand and Upper Limb Research Institute, Brisbane Private Hospital, Spring Hill, QLD, Australia
- School of Medicine, The University of Queensland, St Lucia, QLD, Australia
- The Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - David J Graham
- Australian Research Collaboration on Hands (ARCH), Mudgeeraba, QLD, Australia
- Department of Musculoskeletal Services, Gold Coast University Hospital, Southport, QLD, Australia
- Griffith University School of Medicine and Dentistry, Southport, QLD, Australia
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Tohidi M, Mann SM, Groome PA. Total hip arthroplasty versus hemiarthroplasty for treatment of femoral neck fractures : a population-based analysis of practice variation in Ontario, Canada. Bone Joint J 2023; 105-B:180-189. [PMID: 36722059 DOI: 10.1302/0301-620x.105b2.bjj-2022-0878.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIMS This study aimed to describe practice variation in the use of total hip arthroplasty (THA) for older patients with femoral neck fracture and to determine the association between patient, surgeon, and institution factors and treatment with THA. METHODS We performed a cross-sectional analysis of 49,597 patients aged 60 years and older from Ontario, Canada, who underwent hemiarthroplasty or THA for femoral neck fracture between 2002 and 2017. This population-based study used routinely collected healthcare databases linked through ICES (formerly known as the Institute for Clinical Evaluative Sciences). Multilevel logistic regression modelling was used to quantify the association between patient, surgeon, and institution-level variables and whether patients were treated with THA. Variance partition coefficient and median odds ratios were used to estimate the variation attributable to higher-level variables and the magnitude of effect of higher-level variables, respectively. RESULTS Over the study period, 9.4% of patients (n = 4,638) were treated with THA. Patient factors associated with higher likelihood of treatment by THA included: younger age, male sex, and diagnosis with rheumatoid arthritis. Long-term care residence, use of home care services prior to hip fracture, diagnosis of dementia, higher comorbidity burden, and the most marginalized group were negatively associated with treatment by THA. Treating surgeon and institution accounted for 54.2% and 17.8% of the total variation in treatment with THA, respectively. Surgeon volume of THA procedures in the 365 days prior to surgery was the strongest higher-level predictor of treatment with THA. Specific treating surgeons and institutions still accounted for significant proportions of the variability in treatment with THA (40.3% and 19.5% of total observed variation, respectively) after controlling for available patient, surgeon, and institution-level variables. CONCLUSION The strongest predictors for treatment of patients with femoral neck fracture with THA were patient age, treating surgeon, and treating institution. This practice variation highlights differential access to care for patients.Cite this article: Bone Joint J 2023;105-B(2):180-189.
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Affiliation(s)
- Mina Tohidi
- Department of Public Health Sciences, Queen's University, Kingston, Canada.,Department of Surgery, Queen's University, Kingston, Canada
| | - Stephen M Mann
- Department of Surgery, Queen's University, Kingston, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, Canada.,Department of Surgery, Queen's University, Kingston, Canada.,Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen's University, Kingston, Canada
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Crijns T, Al Salman A, Bashour L, Ring D, Teunis T. Which patient and surgeon characteristics are associated with surgeon experience of stress during an office visit? PEC Innov 2022; 1:100043. [PMID: 37213725 PMCID: PMC10194092 DOI: 10.1016/j.pecinn.2022.100043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 04/11/2022] [Accepted: 04/16/2022] [Indexed: 05/23/2023]
Abstract
Objective To determine clinician and patient factors associated with the surgeon feelings of stress, futility, inadequacy, and frustration during an office visit. Methods A survey-based experiment presented clinical vignettes with randomized patient factors (such as symptom intensity, the number of prior consultations, and involvement in a legal dispute) and feeling behind schedule in order to determine which are most related to surgeon ratings of stress, futility, inadequacy, and frustration on 11-point Likert scales. Results Higher surgeon stress levels were independently associated with women patients, multiple prior consultations, a legal dispute, disproportionate symptom intensity, and being an hour behind in the office. The findings were similar for feelings of futility, inadequacy, and frustration. Conclusion Patient factors potentially indicative of mental and social health opportunities are associated with greater surgeon-rated stress and frustration. Innovation Trainings for surgeon self-awareness and effective communication can transform stressful or adversarial interactions into an effective part of helping patients get and stay healthy by diagnosing and addressing psychosocial aspects of the illness. Level of evidence N/a.
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Affiliation(s)
- Tom Crijns
- Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Aresh Al Salman
- Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Laura Bashour
- Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - David Ring
- Dell Medical School, The University of Texas at Austin, Austin, TX, USA
- Corresponding author at: Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Health Discovery Building; MC Z0800, 1701 Trinity St., Austin, TX 78712, USA.
| | - Teun Teunis
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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He K, Hills-Dunlap JL, Kashtan MA, Riley H, Henry OS, Graham DA, Wynne N, Cramm SL, Rangel SJ. Frequency of Potentially Avoidable Surgical Referrals for Asymptomatic Umbilical Hernias in Children. J Surg Res 2022; 277:290-295. [PMID: 35525211 PMCID: PMC9446374 DOI: 10.1016/j.jss.2022.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/10/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The American Association of Pediatrics released guidelines in 2019 recommending delay of surgical referral in children with asymptomatic umbilical hernias until 4-5 y of age. The purpose of this study was to assess contemporary rates of potentially avoidable referrals in this cohort of children, and to assess whether rates have decreased following guideline release. METHODS Retrospective analysis of umbilical hernias referrals evaluated at a single pediatric surgery clinic from October 2014 to August 2021. Potentially avoidable referrals (PAR) were defined as asymptomatic, non-enlarging umbilical hernia referrals in a child 3 y of age or younger without a history of incarceration. Referral indication, disposition following clinic visit, and rates of PAR were compared before and after guideline release. RESULTS A total of 803 umbilical hernia referrals were evaluated, of which 48% were in children 3 y of age or younger at time of evaluation ("early" referrals). 33% of all referrals and 68% of early referrals were categorized as a PAR, and rates were similar before and after guideline release (all referrals: 32% versus 33%, P = 0.94; early referrals: 68% versus 67%, P = 0.94). Of the 333 early referrals who were managed expectantly per guideline recommendations, 2 (0.6%) developed incarceration which was managed with successful reduction and interval repair. CONCLUSIONS One-third of all referrals for umbilical hernia evaluation are potentially avoidable, and this rate did not change following release of American Academy of Pediatrics guidelines. Aligning expectations between surgeons and referring providers through improved education and guideline dissemination may reduce avoidable visits, lost caregiver productivity, and exposure to potentially avoidable surgery.
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Affiliation(s)
- Katherine He
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | | | - Mark A Kashtan
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Heather Riley
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Owen S Henry
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Dionne A Graham
- Boston Children's Hospital, Center for Applied Pediatric Quality Analytics, Boston, Massachusetts
| | - Nicole Wynne
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts.
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Sakowski JA, Song PH. The Extent Hospital Organizational Factors Influence Inpatient Care Delivery: A Case Study Looking at Knee and Hip Replacement Surgery. Health Serv Insights 2022; 15:11786329221109303. [PMID: 35813564 PMCID: PMC9260580 DOI: 10.1177/11786329221109303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/24/2022] [Indexed: 11/25/2022] Open
Abstract
There is a body of Implementation and Dissemination research describing the
importance of “context”—the characteristics describing the setting where a
process or innovation occurs—when evaluating delivery, outcomes and cost of
health services. These contextual factors, which can occur at the system,
organization, or provider level, may either facilitate or erect barriers to the
utilization of evidence-based practices and the outcomes achieved. This paper
examines the influence of organizational structure and operating environment
characteristics of where inpatient health care is delivered, controlling for
patient and provider characteristics, on health services delivery and outcomes
achieved. We used inpatient cost-of-care to represent the bundle of services
provided to patients receiving primary knee and hip replacement procedures. Data
includes patient level data from discharge records for 62 140 knee replacements
and 42 392 hip replacements from the 2015 AHRQ Healthcare Cost and Utilization
Project State Inpatient Discharge database and hospital characteristics from the
2015 American Hospital Association survey. Multi-level linear estimation models
controlling for patient and payer characteristics were employed to assess the
impact of specific organizational and operating environment factors. We found
that although patient and payer characteristics significantly impacted the
inpatient cost of care, there is significant variation between hospitals and
among physicians within a hospital beyond what can be explained by patient,
payer and local price effect characteristics. Organizational and physician
characteristics that had the most significant impact on cost of care included
the volume of services provided, urban location, and for-profit ownership. These
factors can inform future policy and program design and evaluation.
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Affiliation(s)
- Julie Ann Sakowski
- Associate Professor of Health Care Management, Appalachian State University, Boone, NC, USA
| | - Paula H Song
- Richard M. Bracken Professor and Chair, Department of Health Administration, Virginia Commonwealth University, Richmond, VA, USA
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Senders JT, Maas SLN, Draaisma K, McNulty JJ, Ashby JL, Hofer I, van Solinge WW, Berg MT, Snijders TJ, Seute T, Robe PA, Gormley WB, Smith TR, Broekman MLD. International practice variation in perioperative laboratory testing in glioblastoma patients-a retrospective cohort study. Acta Neurochir (Wien) 2022; 164:385-92. [PMID: 34997355 DOI: 10.1007/s00701-021-05090-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/02/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE Although standard-of-care has been defined for the treatment of glioblastoma patients, substantial practice variation exists in the day-to-day clinical management. This study aims to compare the use of laboratory tests in the perioperative care of glioblastoma patients between two tertiary academic centers-Brigham and Women's Hospital (BWH), Boston, USA, and University Medical Center Utrecht (UMCU), Utrecht, the Netherlands. METHODS All glioblastoma patients treated according to standard-of-care between 2005 and 2013 were included. We compared the number of blood drawings and laboratory tests performed during the 70-day perioperative period using a Poisson regression model, as well as the estimated laboratory costs per patient. Additionally, we compared the likelihood of an abnormal test result using a generalized linear mixed effects model. RESULTS After correction for age, sex, IDH1 status, postoperative KPS score, length of stay, and survival status, the number of blood drawings and laboratory tests during the perioperative period were 3.7-fold (p < 0.001) and 4.7-fold (p < 0.001) higher, respectively, in BWH compared to UMCU patients. The estimated median laboratory costs per patient were 82 euros in UMCU and 256 euros in BWH. Furthermore, the likelihood of an abnormal test result was lower in BWH (odds ratio [OR] 0.75, p < 0.001), except when the prior test result was abnormal as well (OR 2.09, p < 0.001). CONCLUSIONS Our results suggest a substantially lower clinical threshold for ordering laboratory tests in BWH compared to UMCU. Further investigating the clinical consequences of laboratory testing could identify over and underuse, decrease healthcare costs, and reduce unnecessary discomfort that patients are exposed to.
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Enwere EK, Wang D, Guo M, Naugler C, Lang E. The mean abnormal result rates of laboratory tests ordered in the emergency department: shooting percentage insights from a multi-centre study. CAN J EMERG MED 2022; 24:35-38. [PMID: 34582008 DOI: 10.1007/s43678-020-00014-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/21/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE While there is concern about excessive laboratory test ordering in the ED, it is difficult to quantify the problem. One solution involves the Mean Abnormal Result Rate (MARR), which is the proportion of tests ordered that return abnormal results. The primary objective of this study was to calculate MARR scores, and factors associated with MARR scores, for tests ordered between April 2014 and March 2019 at adult EDs in Calgary. METHODS Administrative data were obtained for 40 laboratory tests that met selection criteria. One possible MARR correlate, physician experience, was quantified for 209 ED physicians as number of years since licensure. Analyses were descriptive where appropriate for whole-population data. RESULTS The condensed dataset comprised 3,395,312 test results on 415,653 unique patients. The aggregate 5-year MARR score was 40.1%. The highest per-test score was for BNP (80.5%), while the lowest was for glucose (7.9%). MARR scores were higher for nurse-initiated orders than for physician-initiated orders (44.7% vs. 38.1%). The MARR score correlated inversely with number of tests per order (r = - 0.90; 95% confidence interval [CI] - 0.65 to - 0.94; p < 0.001) and directly with physician experience (r = 0.28, 95% CI 0.20 to 0.27; p < 0.001). CONCLUSION This is the first study to measure MARR scores in an ED setting. While lower scores (close to 5%) are less optimal in principle, ideal scores will depend on the clinical context in which tests are used. However, once departmental benchmarks are established, MARR score-monitoring allows efficient tracking of ordering practices across millions of tests.
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Affiliation(s)
- Emeka K Enwere
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Dongmei Wang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N2, Canada
| | - Maggie Guo
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher Naugler
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eddy Lang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N2, Canada.
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Stanley SP, Truong EI, DeMario BS, Ladhani HA, Tseng ES, Ho VP, Kelly ML. Variations in Discharge Destination Following Severe TBI across the United States. J Surg Res 2021; 271:98-105. [PMID: 34875550 DOI: 10.1016/j.jss.2021.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 10/14/2021] [Accepted: 10/17/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Discharge destination after traumatic brain injury (TBI) may be influenced by non-patient factors such as regional or institutional practice patterns. We hypothesized that non-patient factors would be associated with discharge destination in severe TBI patients. METHODS All patients in the ACS Trauma Quality Improvement Program 2016 data set with severe TBI, defined as head Abbreviated Injury Scale ≥3, were categorized by discharge destination. Logistic regression was used to assess factors associated with each destination; odds ratios and 95% confidence level are reported. Regressions were adjusted for age, gender, race, insurance, GCS, ISS, polytrauma, mechanism, neurosurgical procedure, geographic region, teaching status, trauma center level, hospital size, and neurosurgeon group size. RESULTS 75,690 patients met inclusion criteria. 51% were discharged to home, 16% to rehab, 14% to SNF, and 11% deceased. Mortality was similar across geographic region, teaching status, and hospital size. Southern patients were more likely to be discharged to home while Northeastern patients were more likely to be discharged to rehab. Treatment by groups of 3 or more neurosurgeons was associated with SNF discharge as was treatment at community or non-teaching hospitals. Patients treated at larger hospitals were less likely to be discharged to rehab and more likely to go to SNF. CONCLUSIONS Geographic region, neurosurgeon group size, teaching status, and hospital size are significantly associated with variation in discharge destination following severe TBI. Regional and institutional variation in practice patterns may play important roles in recovery for some patients with severe TBI.
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Salomons G, Nakonechny K, Neath C, Chin L, Keller H, Chan GH. Medical physics external beam plan review: What contributes to the variability? Phys Med 2021; 89:293-302. [PMID: 34488178 DOI: 10.1016/j.ejmp.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/12/2021] [Accepted: 08/06/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE In this article we report on the results of a survey of physics plan review practices conducted by the Cancer Care Ontario Communities of Practice and the variations in practice between and within centers. METHODS The medical physicists at each center worked together to complete the survey and submit a single response for that center. A 4-point Likert scale, used to report the variation in practice at each center, was quantified into two parameters: "Intra-center variation", the distribution of responses within the center, and "Variation between centers", the difference between the center's response and the provincial mean. These metrics were correlated with center characteristics to identify factors that impacted on variations in practice. RESULTS Bolus and heterogeneity correction were the only two items checked by all physicists in all centers. In more than half of the centers, image registration and DVH binning are not likely checked by physics. A significant difference in the variation between centers is observed for centers that used a single vendor's products. Centers that used an official checklist indicated higher levels and a wider range of Intra-center variation. Higher workload did not affect the variation in checking patterns between physicists in the same center. CONCLUSIONS The effect of a center's resources on their checking practice suggest that local environment and workflow be accounted for when implementing TG275 guidelines. The observation that standardized checklists did not reduce checking variability point to the importance of following the checklist development guidelines in MPPG4 to avoid ineffective checklists.
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Aaij AGL, Wermelink B, Haalboom M, Vahl AC, Meerwaldt R, Geelkerken RH. Real World Practice Deviation from Nationwide Guidelines in Patients with Intermittent Claudication. Eur J Vasc Endovasc Surg 2021; 62:432-438. [PMID: 34217598 DOI: 10.1016/j.ejvs.2021.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/19/2021] [Accepted: 05/02/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Patients with intermittent claudication (IC) are initially treated with supervised exercise therapy (SET), as advised by national and international guidelines. Dutch health insurance companies and the Dutch National Health Care Institute suggested an 87% compliance rate with these guidelines in the Netherlands in 2017 and judged this to be undesirably low. The aim of this study was to evaluate compliance with IC guidelines and to elaborate on the reasons for deviating from them (practice variation) in a large teaching hospital. METHODS A retrospective single centre cohort study was conducted at a large teaching hospital in the Netherlands. In total, 420 patients with newly diagnosed IC between 1 January 2017 and 31 December 2018 were analysed. Data included risk profiles and prescribed therapies. RESULTS For all 420 included patients, the compliance rate with the guidelines for SET was 80.5%. The rate of adequately motivated and defensible practice variation was 15.7%; the rate of unjustified practice variation was 3.8%. Meaningful care was seen in 96.2% of cases. CONCLUSION Deviation from IC guidelines was found in 19.5% of patients. Almost three quarters of this deviation can be explained by the decision to provide personalised, meaningful care.
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Affiliation(s)
- Anne G L Aaij
- Medisch Spectrum Twente, Department of Vascular Surgery, Enschede, the Netherlands
| | - Bryan Wermelink
- Medisch Spectrum Twente, Department of Vascular Surgery, Enschede, the Netherlands; University of Twente, Multi-Modality Medical Imaging group, TechMed Centre, Enschede, the Netherlands.
| | - Marieke Haalboom
- Medisch Spectrum Twente, Medical School Twente, Enschede, the Netherlands
| | | | - Robbert Meerwaldt
- Medisch Spectrum Twente, Department of Vascular Surgery, Enschede, the Netherlands
| | - Robert H Geelkerken
- Medisch Spectrum Twente, Department of Vascular Surgery, Enschede, the Netherlands; University of Twente, Multi-Modality Medical Imaging group, TechMed Centre, Enschede, the Netherlands
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van der Lee APM, Hoogendoorn A, de Haan L, Beekman ATF. Discontinuity of psychiatric care for patients with schizophrenia, relation to previous psychiatric care and practice variation between providers: a retrospective longitudinal cohort study. BMC Psychiatry 2021; 21:319. [PMID: 34187433 PMCID: PMC8244203 DOI: 10.1186/s12888-021-03319-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 06/09/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Patients with schizophrenia need continuous integrated healthcare, but many discontinue their treatment, often experiencing adverse outcomes. The first objective of this study is to assess whether patient characteristics or treatment history are associated with discontinuity of psychiatric elective care. The second objective is to assess whether practice variation between providers of psychiatric care contributes to discontinuity of elective care. METHODS A large registry-based retrospective cohort of 9194 schizophrenia patients, who were included if they received elective psychiatric care in December 2014-January 2015. Logistic regression models were used to identify predictive factors of discontinuity of care. The dependent variable was the binary variable discontinuity of care in 2016. Potential independent predictive variables were: age, sex, urbanization, and treatment history in 2013-2014. Practice variation between providers was assessed, adjusting for the case mix of patients regarding their demographic and care utilization characteristics. RESULTS 12.9% of the patients showed discontinuity of elective psychiatric care in the follow-up year 2016. The risk of discontinuity of care in 2016 was higher in younger patients (between age 18 and 26), patients with a history of receiving less elective psychiatric care, more acute psychiatric care, more quarters with elective psychiatric care without antipsychotic medication, or receiving no elective treatment at all. No evidence for practice variation between providers was found. CONCLUSIONS Our findings show that the pattern of previous care consumption is an important prognostic factor of future discontinuity of elective care. We propose that previous care consumption can be used to design strategies to improve treatment retention and focus resources on those most at risk of dropping out.
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Affiliation(s)
- Arnold P. M. van der Lee
- grid.7177.60000000084992262Department Psychiatry Amsterdam University Medical Centre – location VUmc, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands
| | - Adriaan Hoogendoorn
- grid.7177.60000000084992262Department Psychiatry Amsterdam University Medical Centre – location VUmc, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands
| | - Lieuwe de Haan
- grid.5650.60000000404654431Department Psychiatry Amsterdam University Medical Centre – location AMC, Amsterdam, The Netherlands
| | - Aartjan T. F. Beekman
- grid.7177.60000000084992262Department Psychiatry Amsterdam University Medical Centre – location VUmc, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands
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Bouchard ME, Stewart DH, Hall M, Many BT, Vacek JC, Papastefan S, Van Arendonk K, Abdullah F, Goldstein SD. Trends in gastrostomy tube placement with concomitant Nissen fundoplication for infants and young children at Pediatric Tertiary Centers. Pediatr Surg Int 2021; 37:617-625. [PMID: 33486562 DOI: 10.1007/s00383-020-04845-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/27/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE In infants and toddlers, gastrostomy tube placement (GT) is typically accompanied by consideration of concomitant Nissen fundoplication (NF). Historically, rates of NF have varied across providers and institutions. This study examines practice variation and longitudinal trends in NF at pediatric tertiary centers. METHODS Patients ≤ 2 years who underwent GT between 2008 and 2018 were identified in the Pediatric Health Information System database. Patient demographics and rates of NF were examined. Descriptive statistics were used to evaluate the variation in the proportion of GT with NF at each hospital, by volume and over time. RESULTS 40,348 patients were identified across 40 hospitals. Most patients were male (53.8%), non-Hispanic white (49.5%) and publicly-insured (60.4%). Rates of NF by hospital varied significantly from 4.2 to 75.2% (p < 0.001), though were not associated with geographic region (p = 0.088). Rates of NF decreased from 42.8% in 2008 to 14.2% in 2018, with a mean annual rate of change of - 3.07% (95% CI - 3.53, - 2.61). This trend remained when stratifying hospitals into volume quartiles. CONCLUSION There is significant practice variation in performing NF. Regardless of volume, the rate of NF is also decreasing. Objective NF outcome measurements are needed to standardize the management of long-term enteral access in this population.
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Affiliation(s)
- Megan E Bouchard
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA.
| | - Danielle Howard Stewart
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS, USA
| | - Benjamin T Many
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Jonathan C Vacek
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Steven Papastefan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Kyle Van Arendonk
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
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Geerdink TH, Uijterwijk BA, Meijer DT, Sierevelt IN, Mallee WH, van Veen RN, Goslings JC, Haverlag R. Adoption of direct discharge of simple stable injuries amongst (orthopaedic) trauma surgeons. Injury 2021; 52:774-779. [PMID: 33276960 DOI: 10.1016/j.injury.2020.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/04/2020] [Accepted: 11/10/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The importance of routine follow-up of several relatively simple stable injuries (SSIs) is questionable. Multiple studies show that direct discharge (DD) of patients with SSIs from the Emergency Department results in patient outcomes and experiences comparable to 'standard care' with outpatient follow-up. The purpose of this study was to evaluate to which extent DD of SSIs has been adopted amongst trauma and orthopedic surgeons internationally, and to assess the variation in the management of these common injuries. METHODS An online survey was sent to members of an international trauma- and orthopaedic surgery collaboration. Participants, all trauma- or orthopaedic surgeons, were presented with eleven hypothetical cases of patients with simple stable injuries in which they were asked to outline their treatment plan regarding number of follow-up appointments and radiographs, physiotherapy and when to start functional movement. The primary outcome was the proportion of surgeons selecting direct discharge (i.e. zero scheduled appointments), per injury. Secondary outcomes included clinical agreement (>80% of respondents answering similarly) on total number of follow-up appointments (0, 1 or ≥2), radiographs (0, 1 or ≥2), routine physiotherapy referral (yes/no) and when to start functional movement (weeks). RESULTS 138 of 667 (20.7%) surgeons completed the survey. Adoption of direct discharge ranged from 4-45% of case examples. In 10 out of 11 cases, less than 25% of surgeons selected direct discharge. Clinical agreement regarding number of appointments and when to start functional movement was not reached for any of the injuries. There was clinical agreement on number of radiographs for one injury and for four injuries regarding routine referral to a physiotherapist. DISCUSSION Despite available evidence, DD of SSIs has not been widely adopted worldwide. Practice variation still exists even for these common injuries. This variation suggests inefficiency and consequently unnecessarily high healthcare costs. (Orthopaedic) trauma surgeons are encouraged to evaluate their current treatment protocols of SSIs.
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Affiliation(s)
- T H Geerdink
- Trauma Surgery, OLVG Amsterdam, The Netherlands.
| | | | - D T Meijer
- Resident Orthopaedic Surgery, Amsterdam UMC - Location AMC, The Netherlands
| | | | - W H Mallee
- Orthopaedic Surgery, OLVG Amsterdam, The Netherlands
| | | | | | - R Haverlag
- Trauma Surgery, OLVG Amsterdam, The Netherlands
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Hills-Dunlap JL, Anandalwar SP, Kashtan MA, Graham DA, Rangel SJ. Contemporary practice and perceptions surrounding the management of asymptomatic umbilical hernias in children: A survey of the American Pediatric Surgical Association. J Pediatr Surg 2020; 55:2052-7. [PMID: 32122639 DOI: 10.1016/j.jpedsurg.2020.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 02/01/2020] [Accepted: 02/06/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE To explore variation in perceptions regarding the natural history of asymptomatic umbilical hernias, and to characterize the influence of clinical and nonclinical factors on decision-making surrounding timing of repair. METHODS This was a survey of the American Pediatric Surgical Association. Branching logic and Likert scale questions were used to explore perceptions surrounding natural history (risk of complications and likelihood of spontaneous closure), preferred age for repair, and influence of anatomic, caregiver, sociodemographic, and biological factors on operative timing. RESULTS 44% of members completed the survey (371/846). The most common age respondents would consider elective repair was 3 years (37%), although the majority preferred to wait until 4 or 5 years (54%). Most respondents estimated a <1% risk of complications for unrepaired defects, and much greater variability was found in the perceived likelihood of spontaneous closure over time. Decision-making surrounding operative timing was most influenced by anatomic factors (larger defects, proboscoid changes, and interval growth) and parental anxiety surrounding need for emergency surgery, cosmesis, and stigma of parental neglect. CONCLUSION Practice and perceptions surrounding management of asymptomatic umbilical hernias vary widely. More robust epidemiological data are needed to define the likelihood of spontaneous closure in the context of age and physical exam findings. Collaborative efforts between surgeons and referring providers are also needed to optimize management of caregiver anxiety and expectations surrounding need for surgical referral and repair. LEVEL OF EVIDENCE Level V (expert opinion).
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Berger CA, Kityamuwesi A, Crowder R, Lamunu M, Kunihira Tinka L, Ggita J, Sanyu Nakate A, Namale C, Oyuku D, Chen K, Turyahabwe S, Cattamanchi A, Katamba A. Variation in tuberculosis treatment outcomes and treatment supervision practices in Uganda. J Clin Tuberc Other Mycobact Dis 2020; 21:100184. [PMID: 33204851 PMCID: PMC7648165 DOI: 10.1016/j.jctube.2020.100184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Background Variation in healthcare delivery is increasingly recognized as an important metric of healthcare quality. Directly observed therapy (DOT) has been the standard of care for tuberculosis (TB) treatment supervision for decades based on World Health Organization (WHO) guidelines. However, variation in implementation of DOT and associated TB treatment supervision practices remains poorly defined. Methods We collected individual patient data from TB treatment registers at 18 TB treatment units in Uganda including District Health Centers, District Hospitals, and Regional Referral Hospitals. We also administered a survey and did observations of TB treatment supervision practices by health workers at each site. We describe variation in TB treatment outcomes and TB treatment supervision practices. Results Of 2767 patients treated for TB across the 18 clinical sites between January 1 and December 31, 2017, 1740 (62.9%) were men, most were of working age (median 35 years, interquartile range [IQR] 27 - 46), 2546 (92.0%) had a new TB diagnosis, and nearly half (45.9%, n = 1283) were HIV positive. The pooled treatment success proportion was 69.4% (95% confidence interval [CI] 67.8 - 71.1) but there was substantial variation across sites (range 42.6 - 87.6%, I-squared 92.7%, p < 0.001). The survey and observation of TB treatment practices revealed that the majority of sites practice community-based DOT (66.7%, n = 12) and request a family member, who receives no additional training or supervision, to serve as a treatment supporter (77.8%, n = 14). At TB medication refill visits, all sites screen for side effects and most assess adherence via self-report (83.3%, n = 15). Only 7 (38.9%) sites followed-up patients who missed appointments using either phone calls (22.2%, n = 4/7) or community health workers (16.7%, n = 3/7). All 18 sites counseled patients at treatment initiation, but none provided additional counseling at refill visits other than addressing poor adherence or missed appointments. Conclusion There was substantial variation in implementation of DOT, including observation and documentation of daily dosing, training and supervision of treatment supporters, and follow-up for missed clinic visits. Identifying best practices and reducing uncontrolled variation in the delivery of TB treatment is critical to improving treatment outcomes.
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Affiliation(s)
- Christopher A Berger
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Alex Kityamuwesi
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Rebecca Crowder
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Maureen Lamunu
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | | | - Joseph Ggita
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | | | - Catherine Namale
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Denis Oyuku
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | | | | | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, San Francisco General Hospital, University of California San Francisco, San Francisco, USA.,Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda.,Clinical Epidemiology & Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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Amico F, Anning R, Bendinelli C, Balogh ZJ. Grade III blunt splenic injury without contrast extravasation - World Society of Emergency Surgery Nijmegen consensus practice. World J Emerg Surg 2020; 15:46. [PMID: 32746885 PMCID: PMC7397620 DOI: 10.1186/s13017-020-00319-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/07/2020] [Indexed: 11/25/2022] Open
Abstract
Background Recent trauma guidelines recommend non-operative management for grade III splenic injury without contrast extravasation on computed tomography. Nevertheless, such recommendations rely on low-quality evidence, and practice variation characterizes clinical management for this type of injury. We aimed to identify the role of eleven selected clinical factors influencing the management of grade III splenic injury without contrast extravasation by expert consensus and a modified Delphi approach. Methods A questionnaire was developed with the endorsement of the World Society of Emergency Surgery (WSES). This was delivered and answered live by acute care surgeons attending the 6th WSES congress in Nijmegen in 2019. A dedicated mobile phone application was utilized to collect the answers. All answers were evaluated for areas of discrepancy with an 80% threshold for consensus between respondents. Results Three factors generated discrepancy in opinion for managing this pattern of injury: the patients’ injury severity, the presence of a bleeding diathesis, and an associated intra-abdominal injury. Agreement was obtained for the other eight factors. Conclusion Researchers should focus their efforts on the identified area of discrepancy. Clinicians should use additional care in the presence of the three factors for which discordant opinions were found.
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Affiliation(s)
- Francesco Amico
- Department of Traumatology, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, 2310, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Rebecca Anning
- Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia
| | - Cino Bendinelli
- Department of Traumatology, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, 2310, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, 2310, Australia. .,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia.
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Hills-Dunlap JL, Melvin P, Graham DA, Anandalwar SP, Kashtan MA, Rangel SJ. Variation in surgical management of asymptomatic umbilical hernia at freestanding children's hospitals. J Pediatr Surg 2020; 55:1324-1329. [PMID: 31255325 DOI: 10.1016/j.jpedsurg.2019.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/01/2019] [Accepted: 06/08/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To examine hospital-level variation in the timing of asymptomatic umbilical hernia repair in children. METHODS Retrospective analysis of children undergoing umbilical hernia repair at 38 children's hospitals using the Pediatric Health Information System database (01/2013-12/2017). Early repair was defined as surgery performed at 3 years of age or younger. Repairs were categorized as emergent/urgent if associated with diagnostic or procedural codes indicating obstruction or strangulation, or if they occurred within 2 weeks of an emergency department encounter. Multivariable regression was used to calculate hospital-level observed-to-expected (O/E) ratios for early repair adjusting for emergent/urgent repair and patient characteristics. RESULTS 23,144 children were included, of which 30% underwent early repair (hospital range: 6.9%-54.3%, p ≪ 0.001). Overall, 3.8% of all repairs were emergent/urgent, and higher rates of early repair did not correlate with higher rates of emergent/urgent repair across hospitals (r = -0.10). Following adjustment, hospital-level O/E ratios for early repair varied 8.9-fold (0.19-1.70, p ≪ 0.001). CONCLUSION Timing of asymptomatic umbilical hernia repair varies widely across children's hospitals, and the magnitude of this variation cannot be explained by differences in patient characteristics or the acuity of repair. Many children may be undergoing repair of hernias that may spontaneously close with further observation. LEVEL OF EVIDENCE Level III (retrospective comparative study).
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Affiliation(s)
- Jonathan L Hills-Dunlap
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Patrice Melvin
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA, USA.
| | - Dionne A Graham
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA, USA.
| | - Seema P Anandalwar
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Mark A Kashtan
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Violette PD, Vernooij RWM, Aoki Y, Agarwal A, Cartwright R, Arai Y, Tailly T, Novara G, Baldeh T, Craigie S, Breau RH, Guyatt GH, Tikkinen KAO. An International Survey on the Use of Thromboprophylaxis in Urological Surgery. Eur Urol Focus 2020; 7:653-658. [PMID: 32561453 DOI: 10.1016/j.euf.2020.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/15/2020] [Accepted: 05/27/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The use of perioperative thromboprophylaxis in urological surgery is common but not standardized. OBJECTIVE To characterize international practice variation in thromboprophylaxis use in urological surgery. DESIGN, SETTING, AND PARTICIPANTS We conducted a scenario-based survey addressing the use of mechanical and pharmacological thromboprophylaxis in urological cancer procedures (radical cystectomy [RC], radical prostatectomy [RP], and radical nephrectomy [RN]) among practicing urologists in Canada, Finland, and Japan. The survey presented patient profiles reflecting a spectrum of risk for venous thromboembolism; the respondents described their clinical practice. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The proportion of respondents who routinely used (1) mechanical, (2) pharmacological, and (3) extended pharmacological prophylaxis was stratified by procedure. A logistic regression identified characteristics associated with thromboprophylaxis use. RESULTS AND LIMITATIONS Of 1051 urologists contacted, 570 (54%) participated in the survey. Japanese urologists were less likely to prescribe pharmacological prophylaxis than Canadian or Finnish urologists (p < 0.001 for all procedures). Canadian and Finnish urologists exhibited large variation for extended pharmacological prophylaxis for RP and RN. Finnish urologists were most likely to prescribe extended prophylaxis versus Canadian and Japanese urologists (RC 98%, 84%, and 26%; Open RP 25%, 8%, and 3%; robotic RP 11%, 9%, and 0%; and RN 43%, 7%, and 1%, respectively; p < 0.001 for each procedure). Less variation was found regarding the prescription of mechanical prophylaxis, which was most commonly used until ambulation or discharge. The length of hospital stay was longer in Japan and may bias estimates of extended prophylaxis in Japan. CONCLUSIONS We found large variation in clinical practice regarding pharmacological thromboprophylaxis within and between countries. Knowledge translation of evidence-based guidelines may reduce problematic international variation in practice. PATIENT SUMMARY Use of medications to decrease blood clots after urological cancer surgery differs within and between countries. Closer adherence to urology guidelines addressing the prevention of blood clots may decrease this variation and improve patient outcomes.
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Affiliation(s)
- Philippe D Violette
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Robin W M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Nephrology & Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yoshitaka Aoki
- Department of Urology, University of Fukui Faculty of Medical Sciences, Fukui, Japan
| | - Arnav Agarwal
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rufus Cartwright
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK; Department of Urogynecology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Yoichi Arai
- Department of Urology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Thomas Tailly
- Division of Urology, Department of Surgery, University Hospital Ghent, Ghent, Belgium
| | - Giacomo Novara
- Department of Surgical, Oncological, and Gastroenterological Sciences, Urology Clinic, University of Padua, Padua, Italy
| | - Tejan Baldeh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Samantha Craigie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Rodney H Breau
- Division of Urology, The Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Kari A O Tikkinen
- Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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Vu JV, Sheetz KH, De Roo AC, Hiatt T, Hendren S. Variation in colectomy rates for benign polyp and colorectal cancer. Surg Endosc 2020; 35:802-808. [PMID: 32076864 DOI: 10.1007/s00464-020-07451-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Removal of pre-cancerous polyps on screening colonoscopy is a mainstay of colorectal cancer (CRC) prevention. Complex polyps may require surgical removal with colectomy, an operation with a 17% morbidity and 1.5% mortality rate. Recently, advanced endoscopic techniques have allowed some patients with complex polyps to avoid the morbidity of colectomy. However, the rate of colectomy for benign polyp in the United States is unclear, and variation in this rate across geographic regions has not been studied. We compared regional variation in colectomy rates for CRC versus benign polyp. METHODS We performed a retrospective population-based study of Medicare beneficiaries undergoing colectomy for CRC or benign polyp, using the 100% Medicare Provider Analysis and Review files from 2010 to 2015. We used multivariable linear regression to obtain population-based colectomy rates for CRC and benign polyp at the hospital referral region (HRR) level, adjusted for age, sex, and race. RESULTS Of 280,815 patients, 157,802 (65.8%) underwent colectomy for CRC compared to 81,937 (34.2%) for benign polyp. Across HRRs, colectomy rates varied 5.8-fold for cancer (0.32-1.84 per 1000 beneficiaries). However, there was a 69-fold variation for benign polyp (0.01-0.69). While the rate of colectomy for CRC was correlated with the rate of colectomy for benign polyp (slope = 0.61, 95% CI 0.48-0.75), HRRs with the lowest or highest rates of colectomy for CRC did not necessarily have similarly low or high rates for benign polyp. CONCLUSIONS The use of colectomy for benign polyp is much more variable compared to CRC, suggesting overuse of colectomy for benign polyp in some regions. This variation may stem from provider-level differences, such as endoscopists' referral practice or skill or surgeons' decision to perform colectomy, or from limited access to advanced endoscopists. Interventions to increase endoscopic resection of benign polyps may spare some patients the morbidity and cost of surgery.
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Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.
| | - Kyle H Sheetz
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA
| | - Ana C De Roo
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA
| | - Tadd Hiatt
- Department of Gastroenterology, University of Michigan, Ann Arbor, MI, 48103, USA
| | - Samantha Hendren
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA
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Boersma LJ, Verloop J, Voogd AC, Elkhuizen PHM, Houben R, van Leeuwen AE, Linn S, de Munck L, Pijnappel R, Strobbe L, van Dalen T, Wesseling J, Poortmans P. Radiotherapy after primary CHEMotherapy (RAPCHEM): Practice variation in a Dutch registration study (BOOG 2010-03). Radiother Oncol 2020; 145:201-208. [PMID: 32058873 DOI: 10.1016/j.radonc.2020.01.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/13/2020] [Accepted: 01/18/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND We conducted a prospective cohort study in the Netherlands (RAPCHEM: NCT01279304, BOOG 2010-03) in breast cancer (BC) patients treated with primary systemic therapy (PST), followed by surgery and post-operative radiation therapy (RT) according to a predefined consensus-based study-guideline (SG). The aim of the current analysis is to evaluate adherence to the SG. METHODS From January 2011 to January 2015, patients with cT1-2N1 BC treated in 17 Dutch RT Centres were included. Patients with four or more suspicious nodes at imaging were excluded. SG recommended whole breast RT for patients treated with breast conserving therapy. SG on loco(-regional) RT were defined for three risk groups based on the ypN status: (1) ypN0 (low-risk): RT breast and no RT after mastectomy; (2) ypN1 (intermediate-risk): RT breast or chest wall; (3) ypN2 (high-risk): RT breast or chest wall, including regional lymph nodes. RESULTS We included 848 patients: 292 in the low-risk group; 374 in the intermediate-risk group; 182 in the high-risk group. Overall, 64% of the patients was treated according to the SG; 11% received less RT than the predefined target volumes and 25% received more extensive RT than according to the SG. The largest variation was seen in the intermediate risk group, where only 54% was treated according to the SG. CONCLUSION Substantial deviation from the SG for post-operative RT was observed after PST, especially in patients with an intermediate-risk. Future analyses will evaluate outcome of these patients in relation to risk factors and the actual RT given.
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Affiliation(s)
- Liesbeth J Boersma
- Maastricht University Medical Centre+, Dept. of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Netherlands.
| | - Janneke Verloop
- Netherlands Comprehensive Cancer Organisation, Dept. Research and Development, Utrecht, Netherlands
| | - Adri C Voogd
- Netherlands Comprehensive Cancer Organisation, Dept. Research and Development, Utrecht, Netherlands; Maastricht University Medical Centre+, Dept. Epidemiology, GROW School for Oncology and Developmental Biology, Netherlands
| | - Paula H M Elkhuizen
- Antoni van Leeuwenhoek Ziekenhuis, Dept. Radiotherapy, Amsterdam, Netherlands
| | - Ruud Houben
- Maastricht University Medical Centre+, Dept. of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Netherlands
| | | | - Sabine Linn
- Antoni van Leeuwenhoek Ziekenhuis, Dept. Medical Oncology, Amsterdam, Netherlands
| | - Linda de Munck
- Netherlands Comprehensive Cancer Organisation, Dept. Research and Development, Utrecht, Netherlands
| | - Ruud Pijnappel
- University Medical Centre Utrecht, Dept. Radiology, Utrecht University, Netherlands
| | - Luc Strobbe
- Canisius Wilhelmina Hospital Nijmegen, Dept. Surgery, Nijmegen, Netherlands
| | | | - Jelle Wesseling
- Antoni van Leeuwenhoek Ziekenhuis, Dept. Pathology, Amsterdam, Netherlands
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Samuel SM, Dart A, Filler G, Bitzan M, Pinsk M, Mammen C, Nettel-Aguirre A, Perinpanayagam MA, Takano T, Chanchlani R, Zappitelli M; other members of the Canadian Childhood Nephrotic Syndrome Project Team. The Canadian childhood nephrotic syndrome (CHILDNEPH) study: report on mid-study feasibility, recruitment and main measures. BMC Nephrol 2019; 20:159. [PMID: 31088399 DOI: 10.1186/s12882-019-1320-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 03/29/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND To assess reasons for continuing practice variation in the management of childhood nephrotic syndrome despite expert reviews and guidelines, we are conducting a longitudinal cohort study in children with glucocorticoid sensitive nephrotic syndrome. Objectives of this mid-study report are to describe patient and physician recruitment characteristics, glucocorticoid prescriptions, use of second line agents, biopsy practices, and adherence to study protocol. METHODS Children with new onset nephrotic syndrome and providers are being recruited from all 12 pediatric nephrology centres across Canada with > 2½ years follow-up. Data collection points of observation are over a minimum 36 months. Details of prescribed glucocorticoids and of all second line agents used during treatment are being collected. All relapses are being recorded with time to urinary remission of proteinuria. RESULTS To date, 243 patients (57.1% male) from 12 centres were included. Median number of patients per centre was 29 (range 2-45), and median age of cohort was 7.3 (IQR 4.2) at enrollment. Forty-eight physicians were recruited, median 5 (range 2-8) per site. Median number of relapses per patient year of follow-up was 2.1 (IQR 4). Cumulative dose variability of glucocorticoids prescribed per episode of proteinuria and length of treatment was observed between participating centres. CONCLUSION The Canadian pediatric nephrology community established a longitudinal childhood nephrotic syndrome cohort study that confirms ongoing practice variability. The study will help to evaluate its impact on patient outcomes, and facilitate clinical trial implementation in nephrotic syndrome.
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Angiolillo J, Rosenbloom ST, McPheeters M, Seibert Tregoning G, Rothman RL, Walsh CG. Maintaining automated measurement of Choosing Wisely adherence across the ICD 9 to 10 transition. J Biomed Inform 2019; 93:103142. [PMID: 30853653 DOI: 10.1016/j.jbi.2019.103142] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/03/2019] [Accepted: 03/04/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND It remains unclear how to incorporate terminology changes, such as the International Classification of Disease (ICD) transition from ICD-9 to ICD-10, into established automated healthcare quality metrics. OBJECTIVE To evaluate whether general equivalence mapping (GEM) can apply ICD-9 based metrics to ICD-10 patient data. To develop and validate novel ICD-10 reference codesets. DESIGN Retrospective analysis for eleven Choosing Wisely (CW) metrics was performed using three scripted algorithms on an institutional clinical data warehouse. ICD-10 data were compared against published ICD-9 based metric definitions using two equivalence mapping algorithms. A third algorithm implemented novel reference ICD-10 codes matching the original ICD-9 codes' intent for comparison with patient ICD-10 data. PARTICIPANTS All adult patients seen at Vanderbilt University Medical Center, April - September 2016. MAIN MEASURES The prevalence of eleven CW services during the six-month period. KEY RESULTS The three algorithms found similar prevalence of avoidable CW services, with an unweighted-mean of 8.4% (range: 0.16-65%), or approximately 20,000 CW services out of 240,000 potential cases in 515,406 unique patients. The algorithms' median sensitivity was 0.80 (interquartile range: 0.75-0.95), median specificity was 0.88 (IQR: 0.77-0.94), and median Rand accuracy was 0.84 (IQR: 0.79-0.89). The attributed waste of these eleven services for the period ranged from $871,049 to $951,829 between methods. Accuracy assessment demonstrated that the GEM-based methods suffered recall losses for metrics requiring multistep mapping due to incompleteness, while novel ICD-10 metric definitions avoided these challenges. CONCLUSIONS Comprehensive mapping enables use of legacy metrics across ICD generations, but requires computational complexity that can be avoided with novel ICD-10 based metric definitions. Variation in the dollars attributed to waste due to ICD mapping introduces ambiguity that may affect quality-based reimbursement.
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van Essen TA, den Boogert HF, Cnossen MC, de Ruiter GCW, Haitsma I, Polinder S, Steyerberg EW, Menon D, Maas AIR, Lingsma HF, Peul WC. Variation in neurosurgical management of traumatic brain injury: a survey in 68 centers participating in the CENTER-TBI study. Acta Neurochir (Wien) 2019; 161:435-449. [PMID: 30569224 PMCID: PMC6407836 DOI: 10.1007/s00701-018-3761-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/30/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Neurosurgical management of traumatic brain injury (TBI) is challenging, with only low-quality evidence. We aimed to explore differences in neurosurgical strategies for TBI across Europe. METHODS A survey was sent to 68 centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The questionnaire contained 21 questions, including the decision when to operate (or not) on traumatic acute subdural hematoma (ASDH) and intracerebral hematoma (ICH), and when to perform a decompressive craniectomy (DC) in raised intracranial pressure (ICP). RESULTS The survey was completed by 68 centers (100%). On average, 10 neurosurgeons work in each trauma center. In all centers, a neurosurgeon was available within 30 min. Forty percent of responders reported a thickness or volume threshold for evacuation of an ASDH. Most responders (78%) decide on a primary DC in evacuating an ASDH during the operation, when swelling is present. For ICH, 3% would perform an evacuation directly to prevent secondary deterioration and 66% only in case of clinical deterioration. Most respondents (91%) reported to consider a DC for refractory high ICP. The reported cut-off ICP for DC in refractory high ICP, however, differed: 60% uses 25 mmHg, 18% 30 mmHg, and 17% 20 mmHg. Treatment strategies varied substantially between regions, specifically for the threshold for ASDH surgery and DC for refractory raised ICP. Also within center variation was present: 31% reported variation within the hospital for inserting an ICP monitor and 43% for evacuating mass lesions. CONCLUSION Despite a homogeneous organization, considerable practice variation exists of neurosurgical strategies for TBI in Europe. These results provide an incentive for comparative effectiveness research to determine elements of effective neurosurgical care.
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Affiliation(s)
- Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden, The Netherlands.
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland (UNCH), The Hague, The Netherlands.
| | - Hugo F den Boogert
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maryse C Cnossen
- Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Godard C W de Ruiter
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland (UNCH), The Hague, The Netherlands
| | - Iain Haitsma
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Suzanne Polinder
- Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - David Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Hester F Lingsma
- Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden, The Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland (UNCH), The Hague, The Netherlands
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Sibley M, Roshan A, Alshami A, Catapang M, Jöbsis JJ, Kwok T, Polderman N, Sibley J, Matsell DG, Mammen C; Pediatric Nephrology Clinical Pathway Development Team. Induction prednisone dosing for childhood nephrotic syndrome: how low should we go? Pediatr Nephrol 2018; 33:1539-45. [PMID: 29789934 DOI: 10.1007/s00467-018-3975-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 04/11/2018] [Accepted: 04/30/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Historically, children with nephrotic syndrome (NS) across British Columbia (BC), Canada have been cared for without formal standardization of induction prednisone dosing. We hypothesized that local historical practice variation in induction dosing was wide and that children treated with lower doses had worse relapsing outcomes. METHODS This retrospective cohort study included 92 NS patients from BC Children's Hospital (1990-2010). We excluded secondary causes of NS, age < 1 year at diagnosis, steroid resistance, and incomplete induction due to early relapse. We explored cumulative induction dose and defined dosing quartiles. Relapsing outcomes above and below each quartile threshold were compared including total relapses in 2 years, time to first relapse, and proportions developing frequently relapsing NS (FRNS) or starting a steroid-sparing agent (SSA). RESULTS Cumulative prednisone was widely distributed with approximated median, 1st, and 3rd quartile doses of 2500, 2000, and 3000 mg/m2 respectively. Doses ≤ 2000 mg/m2 showed significantly higher relapses (4.2 vs 2.7), shorter time to first relapse (61 vs 175 days), and higher SSA use (36 vs 14%) compared to higher doses. Doses ≤ 2500 mg/m2 also showed significantly more relapses (3.9 vs 2.2), quicker first relapse (79 vs 208 days), and higher FRNS (37 vs 17%) and SSA use (28 vs 11%). Relapsing outcomes lacked statistical difference in ≤ 3000 vs > 3000 mg/m2 doses. CONCLUSIONS Results strongly justify our development of a standardized, province-wide NS clinical pathway to reduce practice variation and minimize under-treatment. The lowest induction prednisone dosing threshold to minimize future relapsing risks is likely between 2000 and 2500 mg/m2. Further prospective studies are warranted.
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Ogink PT, Teunis T, van Wulfften Palthe O, Sepucha K, Bono CM, Schwab JH, Cha TD. Variation in costs among surgeons for lumbar spinal stenosis. Spine J 2018; 18:1584-1591. [PMID: 29496622 DOI: 10.1016/j.spinee.2018.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/22/2018] [Accepted: 02/13/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar spinal stenosis is a common condition in the elderly for which costs vary substantially by region. Comparing differences between surgeons from a single institution, thereby omitting regional variation, could aid in identifying factors associated with higher costs and individual drivers of costs. The use of decision aids (DAs) has been suggested as one of the possible tools for diminishing costs and cost variation. PURPOSE (1) To determine factors associated with higher costs for treatment of spinal stenosis in the first year after diagnosis in a single institution; (2) to find individual drivers of costs for providers with higher costs; and (3) to determine if the use of DAs can decrease costs and cost variability. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE A total of 10,858 patients in 18 different practices diagnosed with lumbar spinal stenosis between January 2003 and July 2015 in three associated hospitals of a single institution. OUTCOME MEASURES Mean cost for a patient per provider in US dollars within 1 year after diagnosis of lumbar spinal stenosis. METHODS We collected all diagnostic testing, office visits, injections, surgery, and occupational or physical therapy related to lumbar spinal stenosis within 1 year after initial diagnosis. We used multivariable linear regression to determine independent predictors for costs. Providers were grouped in tiers based on mean total costs per patient to find drivers of costs. To assess the DAs effect on costs and cost variability, we matched DA patients one-to-one with non-DA patients. RESULTS Male gender (β 0.10, 95% confidence interval [CI] 0.05-0.15, p<.001), seeing an additional provider (β 0.77, 95% CI 0.69-0.86, p<.001), and having an additional spine diagnosis (β 0.79, 95% CI 0.74-0.84, p<.001) were associated with higher costs. Providers in the high cost tier had more office visits (p<.001), more imaging procedures (p<.001), less occupational or physical therapy (p=.002), and less surgery (p=.001) compared with the middle tier. Eighty-two patients (0.76%) received a DA as part of their care; there was no statistically significant difference between the DA group and the matched group in costs (p=.975). CONCLUSIONS Male gender, seeing an additional provider, and having an additional spine diagnosis were independently associated with higher costs. The main targets for cost reduction we found are imaging procedures and number of office visits. Decision aids were not found to affect cost.
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Affiliation(s)
- Paul T Ogink
- Department of Orthopaedic Surgery, Orthopaedic Spine Center, Massachusetts General Hospital-Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
| | - Teun Teunis
- Department of Plastic Surgery, UMC Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Olivier van Wulfften Palthe
- Department of Orthopaedic Surgery, Orthopaedic Spine Center, Massachusetts General Hospital-Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Karen Sepucha
- Division of General Internal Medicine, Health Decision Sciences Center, Massachusetts General Hospital-Harvard Medical School, 50 Staniford St, Boston, MA 02114, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Orthopaedic Spine Center, Brigham and Women's Hospital-Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Orthopaedic Spine Center, Massachusetts General Hospital-Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Thomas D Cha
- Department of Orthopaedic Surgery, Orthopaedic Spine Center, Massachusetts General Hospital-Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
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Beltempo M, Isayama T, Vento M, Lui K, Kusuda S, Lehtonen L, Sjörs G, Håkansson S, Adams M, Noguchi A, Reichman B, Darlow BA, Morisaki N, Bassler D, Pratesi S, Lee SK, Lodha A, Modi N, Helenius K, Shah PS. Respiratory Management of Extremely Preterm Infants: An International Survey. Neonatology 2018; 114:28-36. [PMID: 29656287 DOI: 10.1159/000487987] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 02/27/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are significant international variations in chronic lung disease rates among very preterm infants yet there is little data on international variations in respiratory strategies. OBJECTIVE To evaluate practice variations in the respiratory management of extremely preterm infants born at < 29 weeks' gestational age (GA) among 10 neonatal networks participating in the International Network for Evaluating Outcomes (iNeo) of Neonates collaboration. METHODS A web-based survey was sent to the representatives of 390 neonatal intensive care units from Australia/New Zealand, Canada, Finland, Illinois (USA), Israel, Japan, Spain, Sweden, Switzerland, and Tuscany (Italy). Responses were based on practices in 2015. RESULTS Overall, 321 of the 390 units responded (82%). The majority of units within networks (40-92%) mechanically ventilate infants born at 23-24 weeks' GA on continuous positive airway pressure (CPAP) with 30-39% oxygen in respiratory distress within 48 h after birth, but the proportion of units that offer mechanical ventilation for infants born at 25-26 weeks' GA at similar settings varied significantly (20-85% of units within networks). The most common respiratory strategy for infants born at 27-28 weeks' GA on CPAP with 30-39% oxygen with respiratory distress within 48 h after birth used by units also varied significantly among networks: mechanical ventilation (0-60%), CPAP (3-82%), intubation and surfactant administration with immediate extubation (0-75%), and less invasive surfactant administration (0-68%). CONCLUSIONS There are marked variations but also similarities in respiratory management of extremely preterm infants between networks. Further collaboration and exploration is needed to better understand the association of these variations in practice with pulmonary outcomes.
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Affiliation(s)
- Marc Beltempo
- Department of Paediatrics, Mount Sinai Hospital, University of Toronto, Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Tetsuya Isayama
- Clinical Epidemiology and Biostatistics, McMaster University, Toronto, Ontario, Canada
| | - Máximo Vento
- Spanish Neonatal Network, Health Research Institute La Fe, Avenida Fernando Abril Martorell, Valencia, Spain
| | - Kei Lui
- Australian and New Zealand Neonatal Network, Royal Hospital for Women, National Perinatal Epidemiology and Statistic Unit, University of New South Wales, Randwick, New South Wales, Australia
| | - Satoshi Kusuda
- Neonatal Research Network Japan, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Liisa Lehtonen
- Department of Pediatrics, Turku University Hospital, University of Turku, Turku, Finland
| | - Gunnar Sjörs
- Swedish Neonatal Quality Register, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Stellan Håkansson
- Swedish Neonatal Quality Register, Department of Pediatrics/Neonatal Services, Umeå University Hospital, Umeå, Sweden
| | - Mark Adams
- Swiss Neonatal Network, Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Brian Reichman
- Israel Neonatal Network, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Centre, Tel Hashomer, Israel
| | - Brian A Darlow
- Australia and New Zealand Neonatal Network, Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Naho Morisaki
- Neonatal Research Network Japan, Department of Social Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Dirk Bassler
- Swiss Neonatal Network, Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simone Pratesi
- TIN Toscane Online, Neonatal Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Shoo K Lee
- Department of Paediatrics, Mount Sinai Hospital, University of Toronto, Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Abhay Lodha
- Pediatrics & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Neena Modi
- UK Neonatal Collaborative, Neonatal Data Analysis Unit, Section of Neonatal Medicine, Department of Medicine, Imperial College London, Chelsea and Westminster Hospital Campus, London, United Kingdom
| | - Kjell Helenius
- Department of Pediatrics, Turku University Hospital, University of Turku, Turku, Finland
| | - Prakesh S Shah
- Department of Paediatrics, Mount Sinai Hospital, University of Toronto, Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
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Abstract
Tracheostomy remains one of the most commonly performed surgical procedures in the setting of acute respiratory failure. Tracheostomy literature focuses on 2 aspects of this procedure: when (timing) and how (technique). Recent trials have failed to demonstrate an effect of tracheostomy timing on most clinically important endpoints. Nonetheless, relative to continued translaryngeal intubation, studies suggest that tracheostomy use is associated with less need for sedation and enhanced patient comfort. Evidence likewise suggests that percutaneous dilational tracheostomy is advantageous with respect to cost and complication profile and should be considered the preferred approach in appropriately selected patients.
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Affiliation(s)
- Bradley D Freeman
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Box 8109, St Louis, MO 63110, USA.
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Verstijnen J, Damude S, Hoekstra HJ, Kruijff S, Ten Tije AJ, Louwman WJ, Bastiaannet E, Stuiver MM. Practice variation in Sentinel Lymph Node Biopsy for melanoma patients in different geographical regions in the Netherlands. Surg Oncol 2017; 26:431-437. [PMID: 29113662 DOI: 10.1016/j.suronc.2017.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/13/2017] [Accepted: 08/29/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Due to the lack of solid evidence for treatment benefit of Sentinel Lymph Node Biopsy (SLNB) as part of loco-regional surgical treatment of non-distant metastatic melanoma, there might be variation in surgical treatment strategies in the Netherlands. The objective of the current study was to assess differences in the performance of SLNB, in geographical regions in the Netherlands, of non-distant metastatic melanoma patients (American Joint Committee on Cancer (AJCC) stage I-III). MATERIALS AND METHODS A total of 28 550 melanoma patients, diagnosed between 2005 and 2013, were included in this population based retrospective study. Data were retrieved from the Netherlands Cancer Registry (NCR). Treatment strategies in 8 regions of the Netherlands were compared according to stage, excluding patients with distant metastasis (AJCC stage IV). RESULTS Throughout the Netherlands, there was substantial practice variation across the regions. The performance of SLNB in patients with clinically unsuspected lymph nodes and Breslow thickness >1.0 mm was significantly different between the regions. In a post hoc analysis, we observed that patients aged over 60 years, female patients and patients with a melanoma located in head and neck have lower odds to receive a SLNB. CONCLUSION There is considerable loco-regional practice variation which cannot completely be explained by the patient and tumor characteristics, in the surgical treatment of non-distant metastatic melanoma patients in the Netherlands. Although national guidelines recommend considering SLNB in all patients with a melanoma thicker than 1 mm, only half of the patients received a SLNB. Future research should assess whether this practice variation leads to unwanted variations in clinical outcome.
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Affiliation(s)
- J Verstijnen
- Department of Medical Oncology, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands.
| | - S Damude
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - H J Hoekstra
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - S Kruijff
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - A J Ten Tije
- Department of Medical Oncology, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands; Department of Medical Oncology, VU Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - W J Louwman
- Netherlands Comprehensive Cancer Organisation, Godebaldkwartier 419, 3511 DT Utrecht, The Netherlands.
| | - E Bastiaannet
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; Department of Gerontology & Geriatrics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
| | - M M Stuiver
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Mukerji A, Shah PS, Shivananda S, Yee W, Read B, Minski J, Alvaro R, Fusch C. Survey of noninvasive respiratory support practices in Canadian neonatal intensive care units. Acta Paediatr 2017; 106:387-393. [PMID: 27783410 DOI: 10.1111/apa.13644] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 10/24/2016] [Indexed: 11/28/2022]
Abstract
AIM To evaluate practice variation with respect to noninvasive respiratory support (NRS) use across Canadian neonatal intensive care units (NICUs). METHODS A web-based survey was sent to all site investigators of the 30 level 3 NICUs participating in the Canadian Neonatal Network. The survey inquired about the use of five commonly described NRS modes. In addition, the presence and adherence to local guidelines were ascertained. Descriptive analyses were performed to identify variations in practice. RESULTS In total, 28 (93%) of the 30 tertiary NICUs responded to the survey. Continuous positive airway pressure (CPAP) was employed universally (100%). High-flow nasal cannula (HFNC) was used in 89% of NICUs, biphasic CPAP in 79% and nasal intermittent positive pressure ventilation (NIPPV) in 54%, and nasal high-frequency ventilation was used in 18% of units. Only 61% of all NRS use was guided by local policies, with the lowest being for HFNC (36%). There was a wide range of settings employed and interfaces used for all NRS modes. CONCLUSION There are significant practice variations in NRS use across Canadian NICUs. Further research is needed to evaluate the significance in relation to pulmonary outcomes to determine optimal NRS strategies.
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Affiliation(s)
- Amit Mukerji
- Department of Pediatrics; McMaster University; Hamilton ON Canada
| | - Prakesh S. Shah
- Department of Pediatrics; University of Toronto; Toronto ON Canada
| | | | - Wendy Yee
- Department of Pediatrics; University of Calgary; Calgary AB Canada
| | - Brooke Read
- Department of Respiratory Therapy; London Health Sciences Centre; London ON Canada
| | - John Minski
- Department of Pediatrics; University of Manitoba; Winnipeg MB Canada
| | - Ruben Alvaro
- Department of Pediatrics; University of Manitoba; Winnipeg MB Canada
| | - Christoph Fusch
- Department of Pediatrics; McMaster University; Hamilton ON Canada
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Abstract
AIM To evaluate practice variation with respect to noninvasive respiratory support (NRS) use across Canadian neonatal intensive care units (NICUs). METHODS A web-based survey was sent to all site investigators of the 30 level 3 NICUs participating in the Canadian Neonatal Network. The survey inquired about the use of five commonly described NRS modes. In addition, the presence and adherence to local guidelines were ascertained. Descriptive analyses were performed to identify variations in practice. RESULTS In total, 28 (93%) of the 30 tertiary NICUs responded to the survey. Continuous positive airway pressure (CPAP) was employed universally (100%). High-flow nasal cannula (HFNC) was used in 89% of NICUs, biphasic CPAP in 79% and nasal intermittent positive pressure ventilation (NIPPV) in 54%, and nasal high-frequency ventilation was used in 18% of units. Only 61% of all NRS use was guided by local policies, with the lowest being for HFNC (36%). There was a wide range of settings employed and interfaces used for all NRS modes. CONCLUSION There are significant practice variations in NRS use across Canadian NICUs. Further research is needed to evaluate the significance in relation to pulmonary outcomes to determine optimal NRS strategies.
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Affiliation(s)
- Amit Mukerji
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Prakesh S Shah
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | | | - Wendy Yee
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Brooke Read
- Department of Respiratory Therapy, London Health Sciences Centre, London, ON, Canada
| | - John Minski
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Ruben Alvaro
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Christoph Fusch
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
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Swartz J, Koziatek C, Theobald J, Smith S, Iturrate E. Creation of a simple natural language processing tool to support an imaging utilization quality dashboard. Int J Med Inform 2017; 101:93-99. [PMID: 28347453 DOI: 10.1016/j.ijmedinf.2017.02.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/10/2017] [Accepted: 02/18/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Testing for venous thromboembolism (VTE) is associated with cost and risk to patients (e.g. radiation). To assess the appropriateness of imaging utilization at the provider level, it is important to know that provider's diagnostic yield (percentage of tests positive for the diagnostic entity of interest). However, determining diagnostic yield typically requires either time-consuming, manual review of radiology reports or the use of complex and/or proprietary natural language processing software. OBJECTIVES The objectives of this study were twofold: 1) to develop and implement a simple, user-configurable, and open-source natural language processing tool to classify radiology reports with high accuracy and 2) to use the results of the tool to design a provider-specific VTE imaging dashboard, consisting of both utilization rate and diagnostic yield. METHODS Two physicians reviewed a training set of 400 lower extremity ultrasound (UTZ) and computed tomography pulmonary angiogram (CTPA) reports to understand the language used in VTE-positive and VTE-negative reports. The insights from this review informed the arguments to the five modifiable parameters of the NLP tool. A validation set of 2,000 studies was then independently classified by the reviewers and by the tool; the classifications were compared and the performance of the tool was calculated. RESULTS The tool was highly accurate in classifying the presence and absence of VTE for both the UTZ (sensitivity 95.7%; 95% CI 91.5-99.8, specificity 100%; 95% CI 100-100) and CTPA reports (sensitivity 97.1%; 95% CI 94.3-99.9, specificity 98.6%; 95% CI 97.8-99.4). The diagnostic yield was then calculated at the individual provider level and the imaging dashboard was created. CONCLUSIONS We have created a novel NLP tool designed for users without a background in computer programming, which has been used to classify venous thromboembolism reports with a high degree of accuracy. The tool is open-source and available for download at http://iturrate.com/simpleNLP. Results obtained using this tool can be applied to enhance quality by presenting information about utilization and yield to providers via an imaging dashboard.
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Affiliation(s)
- Jordan Swartz
- New York University School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, NY, United States.
| | - Christian Koziatek
- New York University School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, NY, United States
| | - Jason Theobald
- Department of Emergency Medicine, Mount Sinai West Hospital, Mount Sinai St Luke's Hospital, New York, NY, United States
| | - Silas Smith
- New York University School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, NY, United States
| | - Eduardo Iturrate
- New York University School of Medicine, Department of Internal Medicine, New York, NY, United States
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Lieu TA, Ray GT, Prausnitz SR, Habel LA, Alexeeff S, Li Y, Ramsey SD, Phelps CE, Chawla N, C O'Neill S, Mandelblatt JS. Oncologist and organizational factors associated with variation in breast cancer multigene testing. Breast Cancer Res Treat 2017; 163:167-176. [PMID: 28224383 DOI: 10.1007/s10549-017-4158-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/13/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Multigene testing for breast cancer recurrence risk became available in 2007, yet many eligible patients remain untested. This study evaluated variation in testing rates, and oncologist and organizational factors associated with variation, in a setting without financial influences on testing. METHODS We conducted a retrospective cohort study using electronic data and oncologist surveys within Kaiser Permanente Northern California, a large integrated health care system. Analyses included all 2974 test eligible patients from 2013 to 2015, 113 oncologists, and 15 practice groups. Receipt of multigene testing was evaluated with generalized linear mixed models. RESULTS Overall, 39% of eligible patients had multigene testing, but rates varied widely among practice groups, ranging from 24 to 48% after case mix adjustment. This 24% difference among practices was greater than the variation associated with most patient characteristics, including comorbidities and race/ethnicity, and similar to that associated with tumor size. Practice group and oncologist factors were statistically significant contributors to the variation in testing after adjusting for patient factors. Patients were more likely to be tested if they had a female oncologist (aOR 1.60, 95% CI 1.21-2.12) or were in a practice whose chief had a high testing rate (aOR 1.20, 95% CI 1.12-1.29 per 10% increase in the percent tested). CONCLUSIONS Oncologist and leadership practices play a key role in the variation in genomic test use for cancer recurrence risk even in a healthcare system without financial barriers to testing and could be a leverage point for implementing desired practice changes for new genomic advances.
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Affiliation(s)
- Tracy A Lieu
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - G Thomas Ray
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Stephanie R Prausnitz
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Laurel A Habel
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Stacey Alexeeff
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Yan Li
- Department of Oncology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Scott D Ramsey
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Neetu Chawla
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Suzanne C O'Neill
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Jeanne S Mandelblatt
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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Pahle AS, Sørli D, Kristiansen IS, Deraas TS, Halvorsen PA. Practice variation in surgical procedures and IUD-insertions among general practitioners in Norway - a longitudinal study. BMC Fam Pract 2017; 18:7. [PMID: 28109245 PMCID: PMC5251308 DOI: 10.1186/s12875-017-0581-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 01/05/2017] [Indexed: 12/05/2022]
Abstract
Background Studies of Primary Health Care (PHC) reveal considerable practice variations in terms of the range of services provided. In Norway, general practitioners (GPs) are traditionally expected to perform IUD-insertions and several surgical procedures as a part of comprehensive PHC. We aimed to investigate variation in the provision of surgical procedures and IUD-insertions across GPs and over time and explore determinants of such variation. Methods Retrospective registry study of Norwegian GPs. From a comprehensive database of GPs’ reimbursement claims, we obtained procedure codes and GP characteristics such as age, gender, list size and municipality characteristics from 2006 through 2013. Multivariable logistic regression models were fitted to explore determinants of practice variation. Results We extracted data from 4,828 GPs. In 2013, 91.0, 76.1 and 74.8% were reimbursed at least once for minor and major surgical procedures and IUD-insertion, respectively. Female GPs had lower odds for performing major surgical procedures (OR 0.38, 95% CI 0.32–0.45) and higher odds for performing IUD-insertions (OR 6.28, 95% CI 4.47–8.82) than male GPs. Older GPs and GPs with shorter patient lists were less likely to perform surgical procedures. GPs with longer patient lists had higher odds for performing IUD-insertions. The proportion of GPs performing surgical procedures increased over time, while the proportion decreased for IUD-insertions. The number of IUD-insertions in specialist care increased from 12,575 in 2011 to 15 216 (+21.0%) in 2014. Conclusion We observed a large variation in the provision of surgical procedures and IUD-insertions amongst GPs in Norway. The GPs’ age, gender, list size and size of municipality were associated with performing the procedures. Our findings suggest a shift of IUD-insertions from primary to specialist care.
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Affiliation(s)
- Andreas Saxlund Pahle
- Bolteløkka legesenter, Sofiesgt 60, 0160, Oslo, Norway. .,General Practice Research Unit, Department of Community Medicine, UiT- the Arctic University of Norway, P.O.Box 6050, Langnes, 9037, Tromsø, Norway.
| | - Daniel Sørli
- General Practice Research Unit, Department of Community Medicine, UiT- the Arctic University of Norway, P.O.Box 6050, Langnes, 9037, Tromsø, Norway.,Bankgården Legekontor, Sørumsandvegen 69, 1920, Sørum, Norway
| | - Ivar Sønbø Kristiansen
- Department of Health Management and Health Economics, University of Oslo, P.O. Box 1089, Blindern, NO-0317, Oslo, Norway
| | - Trygve S Deraas
- Center of Clinical Documentation and Evaluation, Northern Norway Regional Health Authority, Box 6, N-9038, Tromsø, Norway
| | - Peder A Halvorsen
- General Practice Research Unit, Department of Community Medicine, UiT- the Arctic University of Norway, P.O.Box 6050, Langnes, 9037, Tromsø, Norway
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Mennie JC, Mohanna PN, O'Donoghue JM, Rainsbury R, Cromwell DA. National trends in immediate and delayed post-mastectomy reconstruction procedures in England: A seven-year population-based cohort study. Eur J Surg Oncol 2016; 43:52-61. [PMID: 27776942 DOI: 10.1016/j.ejso.2016.09.019] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 09/14/2016] [Accepted: 09/21/2016] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Little is known about post-mastectomy reconstruction procedural trends in women diagnosed with breast cancer in England. Our aim was to examine patterns of immediate and delayed reconstruction procedures over time and within regions. METHODS Women with breast cancer who underwent unilateral index immediate or delayed post-mastectomy reconstruction between 2007 and 2014 were identified using the National Hospital Episode Statistics database. Women were grouped into categories based on the type of reconstruction procedure. Adjusted rates of implant and free flap reconstructions were then calculated across regional Cancer Networks using a regression model to adjust for age, disease, comorbidities, ethnicity, and deprivation. RESULTS Between 2007 and 2014, 21 862 women underwent immediate reconstruction and 8653 delayed reconstruction. Immediate implant reconstruction increased from 30% to 54%, and immediate free flap reconstruction from 17% to 21%. Adjusted immediate implant and free flap proportions ranged from 17 to 68% and 9-63%, respectively, across regions. Free flaps became more common in the delayed setting, rising from 25% to 42%. However, adjusted rates ranged from 23% to 74% across regions. Networks with high/low rates of free flaps for immediate tended to have high/low rates for delayed reconstruction. CONCLUSION There has been a substantial increase in the use of immediate implant reconstruction in England. In comparison, there has been an increasing use of autologous free flap reconstruction for delayed procedures. Significant regional variation exists in the type of reconstruction performed, and these patterns need to be examined to determine if variation is related to service provision and/or capacity barriers.
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Affiliation(s)
- J C Mennie
- Clinical Effectiveness Unit, Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK; Department of Plastic and Reconstructive Surgery, St Thomas Hospital, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK.
| | - P-N Mohanna
- Department of Plastic and Reconstructive Surgery, St Thomas Hospital, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - J M O'Donoghue
- Department of Plastic and Reconstructive Surgery, Royal Victoria Infirmary, Newcastle Upon Tyne NHS Foundation Trust, Queen Victoria Road, Newcastle-upon-Tyne, NE1 4LP, UK
| | - R Rainsbury
- Department of Breast Surgery, Royal Hampshire County Hospital, Hampshire Hospitals NHS Foundation Trust, Romsey Road, Winchester, SO22 5DG, UK
| | - D A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Sheetz K, Hemmila MR, Duby A, Krapohl G, Morris A, Campbell DA, Hendren S. Results of a statewide survey of surgeons' care practices for emergency Hartmann's procedure. J Surg Res 2016; 205:108-14. [PMID: 27621006 DOI: 10.1016/j.jss.2016.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/04/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Emergency general surgery is associated with high morbidity and mortality but has seldom been targeted for practice improvement. The goal of this study was to determine whether perioperative practices vary among surgeons for emergency Hartmann's procedures and whether perioperative care practices are associated with hospitals' complication rates. MATERIALS AND METHODS We conducted a survey of surgeons at 27 Michigan hospitals. Questionnaires focused on preoperative, intraoperative, and postoperative care practices. Hospitals were divided into quartiles of risk-adjusted complication rates. Responses of surgeons at hospitals with the lowest complication rates were compared to those with the highest, to determine whether there were systematic differences. Qualitative content analysis was performed for open-ended questions. RESULTS A total of 106 surgeons returned questionnaires (response rate 49%). We identified variation in use of bowel preparation, ostomy site marking, rectal stump management, ostomy protrusion, skin closure method, antibiotics duration, and ambulation/physical therapy practices. Surgeons from hospitals with low complication rates were more likely to use a clean instrument tray during wound closure (61% versus 11%, P = 0.001) and reported greater use of laparoscopic lavage without resection for emergency diverticulitis cases (31% versus 6%, P = 0.05). Surgeons in the lower complication rate hospitals listed more modifiable care factors in their open-ended responses to questions about reasons for complications. CONCLUSIONS Surgeons' practices vary for emergency Hartmann's procedure. This study serves as a proof of concept that studying surgeons' practices is feasible within a quality collaborative setting. Such data can be used to generate testable hypotheses for performance improvement aimed in high-risk, emergency surgery.
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Affiliation(s)
- Kyle Sheetz
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan; Michigan Surgical Quality Collaborative, Ann Arbor, Michigan.
| | - Mark R Hemmila
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan; Michigan Surgical Quality Collaborative, Ann Arbor, Michigan
| | - Ashley Duby
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Greta Krapohl
- Michigan Surgical Quality Collaborative, Ann Arbor, Michigan
| | - Arden Morris
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan; Michigan Surgical Quality Collaborative, Ann Arbor, Michigan
| | - Darrell A Campbell
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan; Michigan Surgical Quality Collaborative, Ann Arbor, Michigan
| | - Samantha Hendren
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan; Michigan Surgical Quality Collaborative, Ann Arbor, Michigan
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Gross TS, McCracken C, Heiss KF, Wulkan ML, Raval MV. The contribution of practice variation to length of stay for children with perforated appendicitis. J Pediatr Surg 2016; 51:1292-7. [PMID: 26891834 DOI: 10.1016/j.jpedsurg.2016.01.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 01/19/2016] [Accepted: 01/20/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Postoperative length of stay (pLOS) is an easily tracked outcome that reflects health care efficiency and resource utilization. The purpose of this study was to determine the contribution of practice variation on pLOS for children with perforated appendicitis. METHODS Children ages 2-18years with appendectomy for complicated appendicitis were selected from the National Surgical Quality Improvement Program-Pediatric. Extended pLOS (EpLOS) was defined as ≥7days (75th percentile). The contribution of comorbidities, operative traits, and postoperative complications to EpLOS was evaluated using regression models and matched subgroup analyses. RESULTS Of 2585 children with complicated appendicitis in our study, 835 had EpLOS. Regression analysis found that EpLOS was associated with extended operative time (odds ratio (OR) 1.99; 95% confidence interval (CI) 1.63-2.44), dehiscence (OR 13.19; 95% CI 1.52-114.23), wound infection (OR 7.39; 95% CI 2.63-20.80), organ space infection (OR 92.51; 95% CI 34.03-251.50), and pneumonia (OR 4.55; 95% CI 1.06-19.44). Over three-fourths of the variation in pLOS could not be explained by preoperative, intraoperative, or postoperative factors. CONCLUSIONS There is significant variation in pLOS for children undergoing appendectomy that is not accounted for by comorbidities, operative traits, or complications indicating an opportunity to improve outcomes through modifying practice patterns.
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Slaughter JL, Reagan PB, Bapat RV, Newman TB, Klebanoff MA. Nonsteroidal anti-inflammatory administration and patent ductus arteriosus ligation, a survey of practice preferences at US children's hospitals. Eur J Pediatr 2016; 175:775-83. [PMID: 26879388 PMCID: PMC5056586 DOI: 10.1007/s00431-016-2705-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 11/23/2015] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
UNLABELLED We surveyed neonatal leadership at 46 US children's hospitals via web-based survey to identify local preferences and concerns regarding indomethacin prophylaxis, nonsteroidal anti-inflammatory drug (NSAID) treatment, and patent ductus arteriosus (PDA) ligation. We received a 100 % survey response (N = 46). Practice guidelines for prophylactic indomethacin were reported at 28 % of NICUs, for NSAID treatment of PDA at 39 % and for surgical ligation at 27 %. Respondents noted intra-institutional practice variation for indomethacin prophylaxis (33 %), NSAID treatment (70 %), and PDA ligation (73 %). The majority of institutions did not prescribe indomethacin prophylaxis (72 %). For PDA treatment, indomethacin was preferred over ibuprofen (80 %). We validated our survey results via comparison with billing data as documented in the Pediatric Health Information System (PHIS) database, finding that survey responses directly correlated with local billing data (p < 0.0001). At institutions that did not typically administer NSAIDs for PDA closure or surgical PDA ligation, a lack of evidence for their effectiveness in improving long-term outcomes and the risk of treatment-associated adverse effects were the most often cited reasons. CONCLUSION No consensus exists among providers at US children's hospitals regarding prophylactic indomethacin, NSAID treatment, or PDA ligation. Lack of evidence and safety concerns play a prominent role. WHAT IS KNOWN • NSAIDs and surgical PDA ligation are efficacious in preventing intraventricular hemorrhage (IVH) and closing PDA in preterm infants, but have not been shown to improve long-term respiratory, neurodevelopmental, or mortality outcomes. What is New: • Practice preferences for indomethacin prophylaxis, NSAID, and surgical PDA treatment vary both among and within institutions. Lack of treatment effectiveness and the risk of adverse effects are major concerns.
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Affiliation(s)
- Jonathan L Slaughter
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA. .,Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children's Hospital, Columbus, OH, USA.
| | - Patricia B Reagan
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Department of Economics and Center for Human Resource Research, Ohio State University Columbus, OH, USA
| | - Roopali V Bapat
- Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children’s Hospital, Columbus, OH, USA
| | - Thomas B Newman
- Departments of Epidemiology & Biostatistics and Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Mark A Klebanoff
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children’s Hospital, Columbus, OH, USA
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47
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Abstract
Variation in care and outcomes are common in the management of children with surgical diseases. Differences in the availability of resources, patient and family preferences, ever-increasing fiscal pressure, and lack of high-quality data to guide clinical decision making are just a few factors that contribute to both the over and under-utilization of healthcare resources. Identification of data-driven, value-based "best practices" that are sensitive to differences in resource availability and patient preferences may be an important first step in establishing a practical framework for reducing unwarranted practice variation. The goal of this article is to explore the causes and influence of practice variation using appendicitis as a common condition to illustrate key concepts, and to propose solutions to mitigate unwarranted practice variation while preserving the spirit of innovation necessary to advance the field.
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Affiliation(s)
- Danielle B Cameron
- Department of Surgery, Children׳s Hospital Boston, Harvard Medical School, 300 Longwood Ave, Fegan-3, Boston, Massachusetts 02115
| | - Shawn J Rangel
- Department of Surgery, Children׳s Hospital Boston, Harvard Medical School, 300 Longwood Ave, Fegan-3, Boston, Massachusetts 02115.
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48
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Abstract
PURPOSE When surgeons disagree about the role of surgery, patient values and preferences should drive decision-making, but there is evidence that surgeon preferences have substantial influence. Surgeon preferences may relate to surgeon personality. Our primary null hypothesis is that specific personality characteristics (work styles) are not associated with the recommendation for operative treatment accounting for surgeon demographics. PATIENTS AND METHODS We invited members of the Science of Variation Group to assess images of 15 upper extremity injuries with debatable indications for surgery, recommended operative or non-operative treatment, and grade their confidence in this decision (n = 270); subsequently, participants completed the validated Octogram Work and Leadership Style Test (n = 223). We selected injuries that could be treated either operatively or non-operatively including fractures of the clavicle, scapula, humerus, and radius fractures, and proximal and distal bicep ruptures. RESULTS A higher proportion of recommendations for surgery was independently associated with a higher Octogram test pioneer score (β regression coefficient [β] 0.0054, partial R (2) 0.065, 95 % confidence interval [CI] 0.0027-0.0080, P < 0.001) and practice location outside North America and Europe (β 0.13, partial R (2) 0.079, 95% CI 0.073-0.020, P < 0.001) (adjusted R (2) 0.12, P < 0.001). No work styles were associated with more confidence in treatment. CONCLUSIONS A recommendation for discretionary surgery for musculoskeletal injury was related to surgeon personality. Surgeon self-awareness of how their work style can influence their recommendations might make them more receptive to techniques that ensure patient values have more influence than surgeon preferences on treatment decisions.
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Affiliation(s)
- Teun Teunis
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital—Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Stein J. Janssen
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital—Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Thierry G. Guitton
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital—Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Ana-Maria Vranceanu
- Department of Psychiatry, Massachusetts General Hospital—Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Bert Goos
- Online Talent Manager, Claudius Prinsenlaan 126, 4818 CP Breda, The Netherlands
| | - David Ring
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital—Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
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49
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Govers TM, de Kort TBH, Merkx MAW, Steens SCA, Rovers MM, de Bree R, Takes RP. An international comparison of the management of the neck in early oral squamous cell carcinoma in the Netherlands, UK, and USA. J Craniomaxillofac Surg 2015; 44:62-9. [PMID: 26643388 DOI: 10.1016/j.jcms.2015.10.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 10/19/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Early oral cavity squamous cell carcinoma (OCSCC) management appears to vary both within and between countries. Variation in practice can be an indicator of absence of evidence-based management and may negatively influence survival and morbidity. The exact variation and the relationship to differences in guidelines are unknown. This study aimed to report on these variations in the Netherlands, UK, and USA, and to evaluate them. METHODS Information regarding the variation in OCSCC management strategies was obtained from a questionnaire sent to representatives of head and neck cancer centers in the Netherlands, UK, and USA. Within-country and between-country variations were also assessed in light of the different guidelines. RESULTS In total, representatives of 45 centers completed the questionnaire; 10 from the Netherlands, 26 from the UK and 9 from the USA. Our results demonstrate a distinct variation in the diagnoses, treatment and follow-up of OCSCC, both within and between countries. Only a small amount of variation between countries could be linked to differences in guidelines. CONCLUSIONS There is high variation in the management of the neck in OCSCC. There seem to be a need for direct evidence about optimal management decisions to establish more evidence-based management and uniform practice.
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Affiliation(s)
- Tim M Govers
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Tijs B H de Kort
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Matthias A W Merkx
- Department of Oral and Maxillofacial Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stefan C A Steens
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maroeska M Rovers
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands; Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Remco de Bree
- Department of Head and Neck Surgical Oncology, UMC Utrecht Cancer Center, UMCU Utrecht, Utrecht, The Netherlands
| | - Robert P Takes
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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50
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Offerhaus PM, Otten W, Boxem-Tiemessen JCG, de Jonge A, van der Pal-de Bruin KM, Scheepers PLH, Lagro-Janssen ALM. Variation in intrapartum referral rates in primary midwifery care in the Netherlands: a discrete choice experiment. Midwifery 2015; 31:e69-78. [PMID: 25660846 DOI: 10.1016/j.midw.2015.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 01/09/2015] [Accepted: 01/11/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE in midwife-led care models of maternity care, midwives are responsible for intrapartum referrals to the obstetrician or obstetric unit, in order to give their clients access to secondary obstetric care. This study explores the influence of risk perception, policy on routine labour management, and other midwife related factors on intrapartum referral decisions of Dutch midwives. DESIGN a questionnaire was used, in which a referral decision was asked in 14 early labour scenarios (Discrete Choice Experiment or DCE). The scenarios varied in woman characteristics (BMI, gestational age, the preferred birth location, adequate support by a partner, language problems and coping) and in clinical labour characteristics (cervical dilatation, estimated head-to-cervix pressure, and descent of the head). SETTING primary care midwives in the Netherlands. PARTICIPANTS a systematic random selection of 243 practicing primary care midwives. The response rate was 48 per cent (117/243). MEASUREMENTS the Impact Factor of the characteristics in the DCE was calculated using a conjoint analysis. The number of intrapartum referrals to secondary obstetric care in the 14 scenarios of the DCE was calculated as the individual referral score. Risk perception was assessed by respondents׳ estimates of the probability of eight birth outcomes. The associations between midwives׳ policy on management of physiological labour, personal characteristics, workload in the practice, number of midwives in the practice, and referral score were explored. FINDINGS the estimated head-to-cervix pressure and descent of the head had the largest impact on referral decisions in the DCE. The median referral score was five (range 0-14). Estimates of probability on birth outcomes were predominantly overestimating actual risks. Factors significantly associated with a high referral score were: a low estimated probability of a spontaneous vaginal birth (p=0.007), adhering to the active management policy Proactive Support of Labour (PSOL) (p=0.047), and a practice situated in a rural area or small city (p=0.016). KEY CONCLUSIONS there is considerable variation in referral decisions among midwives that cannot be explained by woman characteristics or clinical factors in early labour. A realistic perception of the possibility of a spontaneous vaginal birth and adhering to expectant management can contribute to the prevention of unwarranted medicalisation of physiological childbirth. IMPLICATIONS FOR PRACTICE awareness of variation in referrals and the associated midwife-related factors can stimulate midwives to reflect on their referral behavior. To diminish unwarranted variation, high quality research on the optimal management of a physiological first stage of labour should be performed.
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Affiliation(s)
- Pien M Offerhaus
- KNOV (Royal Dutch Organisation for Midwives), P.O. Box 2001, 3500GA Utrecht, The Netherlands.
| | - Wilma Otten
- TNO Life Style, P.O. Box 2215, 2301 CE Leiden, The Netherlands.
| | | | - Ank de Jonge
- Department of Midwifery Science, AVAG and the EMGO Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
| | | | - Peer L H Scheepers
- Faculty of Social Sciences, Radboud University, P.O. Box 9104, 6500 HE Nijmegen, The Netherlands.
| | - Antoine L M Lagro-Janssen
- Radboud University Nijmegen Medical Centre, Internal Postal Code 118, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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